Attachment L - RSA Badge Request Form.pdf

FBI Base Access Form

REV 1, 31 OCT 16

Form Provided by FBIHQ OSO Security

PLEASE PRINT LEGIBLY

CLASS NO: (If Applicable)

ORGANIZATION:

OFFICE SYMBOL: (If

Applicable)

SOCIAL SECURITY NUMBER:

(REQUIRED FOR ACCESS)

LAST

NAME:

FIRST

NAME:

MIDDLE

NAME:

PERSON TYPE

(CONTRACTOR, ETC)

CLEARANCE:

GRADE/RANK:

POSITION TITLE

PRIMARY CITIZENSHIP: DUAL CITIZENSHIP:

HAIR COLOR

EYE COLOR

HEIGHT (IN)

WEIGHT (LBS)

DATE OF BIRTH

(D/M/Y)

SEX

RACE

BIRTHPLACE

EMAIL ADDRESS:

DATE OF ARRIVAL:

DATE OF DEPARTURE:

HOME ADDRESS:

HOME PHONE:

CITY:

STATE:

ZIP:

SECURITY BADGE REQUEST

SCAN COMPLETED FORM TO HQ_DIV11_RSVS@fbi.gov

NOTES:

1. Bring your vehicle registration if you are driving.

2. Bring proof of insurance or department proof of liability, if applicable.

3. Bring driver’s license and credentials.

4. When you arrive at Gate 9 or Gate 1 your driver’s license will be entered into the system to pull your data – your photograph will be taken and you will be issued a badge and vehicle pass, if applicable.