PLEASE FILL IN ALL BLANKS ON FORM UNLESS OTHERWISE NOTED. A VALID DRIVER’S LICENSE WILL NEED TO BE SUBMITTED FOR WSSC TO MAKE A COPY FOR ITS RECORDS.

APPLICANT NAME

DRIVER’S LICENSE

Family Name

Given Name

Middle Name

State

Number

COMPANY APPLICANT REPRESENTS

CONTACT INFORMATION

HOME

COMPANY

Address

Address

Street (No P.O. Boxes allowed)

Street (No P.O. Boxes allowed)

City

State

Postal Code

City

State

Postal Code

Country

Country

Telephone

Fax

Telephone

Extension

Fax

E-Mail

DESCRIPTION OF INTENDED BUSINESS USE OF WSSC RECORDS/INFORMATION

(Please be as specific as possible)

REFERENCE WHO CAN CONFIRM BUSINESS USE

(Should be applicant’s immediate supervisor or company official who can confirm length of employment, applicant’s position with firm, and related business purpose. If working on project for WSSC, applicant should also list authorized WSSC contact.)

Company Official Contact

Authorized WSSC Contact

Name

Name

Telephone

Extension

Fax

E-Mail

RECORDS/INFORMATION REQUESTED

(check all that apply)

REQUESTED USER ID

(for Internet access only. Must be 6 to 15 characters, no spaces/special characters)

Hard Copies

Internet Access

Electronic Data

To complete the process, the applicant must personally appear at our One-Stop Shop, 14501 Sweitzer Lane, Laurel, MD on the Lobby Level, to sign the application and provide their current, valid driver's license along with their Social Security number.

By signing this application, I certify that this application is complete and accurate to the best of my knowledge and that I have not made any attempt to conceal information. I understand that falsification could be cause for refusal. I also agree to the following terms:

○      WSSC reserves the right to require occasional renewal of this application. If the application is not renewed when required, documents will not be released until application renewal is completed.

○      My company and I will abide by the terms of non-disclosure listed below. Failure to do so may result in permanent revocation of my company’s and my right to access WSSC records/information. In such case, WSSC also reserves the right to demand immediate delivery or return of all WSSC records/information, documents, and files.

Non-disclosure agreement - As a condition to furnishing the applicant with WSSC engineering records/information or Internet access to such, the Applicant and the Applicant’s Company agree to the following:

○      The records/information provided by WSSC shall not be used by the Applicant or the Applicant’s Company other than for the purpose stated on the application form.

○      The records/information will be treated as belonging to WSSC, and shall not, without WSSC’s prior written consent, be disclosed in any manner, in whole or in part, to anyone outside of the Applicant’s Company or within the Applicant’s Company except for purposes involving legitimate business needs for such records/information.