Appendix K. ICE Mutual Agreement Between Government and Employers (IMAGE) Self-Assessment Questionnaire (03/13)

AuthorCharles M. Miller/Daniel Brown/Marcine Anne Seid
ProfessionFounding partner of the Miller Law Offices, Studio City, California/Partner in Fragomen, Del Rey, Bernsen & Loewy LLP's Washington, D.C./Principal attorney of the Seid Law Group, Palo Alto, California
Pages418-426
418 Appendix K
A. Company Information
1. Legally Registered Company Name / DBA
2. Company Address (Street Address, Suite Number, City, State, and Zip Code)
4. Federal Employer Identification Number (EIN) 5. Company Website
6. Federal Contractor?
Yes
No
Non-ProfitProfit Yes No
Yes
No
Country
1.
2.
3.
4.
7. North American Industry Classification
System (NAICS) Code
9. Number of
Employees
Page 1 of 9
8. Business Structure
(If not on the list, please type it in.)
12. Are you a subsidiary?
13. If yes, identify your parent company.
3. Mailing Address (Street Address, Suite Number, City, State, Zip Code, and P.O. Box, if applicable)
14. Where is your parent company located?
(if not on the list, please type it in.)
15. Does your company own any subsidiaries? If yes, list below.
Company Name EIN
10. Secretary of State Business ID Number 11. Where are you registered?
16. Are you profit or non-profit? 17. Does your company handle hazardous materials?
OMB No. 1653-0048
Expiration 02/28/2017
ICE Form 73-028 (03/13)
Instructions: Please complete all items on the application. Once completed, please return the application and any attachments via
e-mail or hard copy delivery to the U.S. Immigration and Customs Enforcement (ICE) IMAGE Coordinator who originally contacted you.
No personal information about individual employees should be included in the application or any attachments. Questions regarding the
application or the IMAGE Program can be submitted to IMAGE@dhs.gov. (If more space is needed, use the Continuation Page.)
DEPARTMENT OF HOMELAND SECURITY
U.S. Immigration and Customs Enforcement
ICE MUTUAL AGREEMENT BETWEEN GOVERNMENT AND EMPLOYERS (IMAGE)
SELF-ASSESSMENT QUESTIONNAIRE

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