36C26119B0030-010.pdf

SECTION II - SPONSOR VERIFICATION (Completed by Sponsor)

6. WORK E-MAIL ADDRESS

2. NICKNAME TO BE USED FOR APPLICANT (Insert last name and first name, if applicable)

PART A - APPLICANT EMPLOYMENT INFORMATION (Completed by Sponsor)

SECTION I - APPLICANT INFORMATION

APPLICANT INFORMATION (Completed by Applicant)

REQUEST FOR PERSONAL IDENTITY VERIFICATION CARD

1. LEGAL NAME OF APPLICANT (Insert last , first , middle and suffix name)

4. SOCIAL SECURITY NO.3. DATE OF BIRTH (MM/DD/YYYY)

7. HOME ADDRESS

5. HOME PHONE NUMBER (Include Area Code) (Optional)

4. EMPLOYMENT STATUS

1. TYPE OF REQUEST

1. SPECIAL SECURITY ACCESS REQUIRED 2. SPECIFY LOCATION OF SPECIAL

SECURITY (i.e. tower, bldg. no., etc.)

3. IS APPLICANT A KEY EMERGENCY RESPONDER, CRITICAL

EMPLOYEE, OR NEITHER?

PART C - PHYSICAL SECURITY ACCESS DATA (Completed by Sponsor)

1. EMPLOYMENT EXPIRATION DATE /CONTRACT END DATE

(MM/DD/YYYY)(For Contractors, Affiliates, and Temporary Employment)

PART E - CONTRACTORS, AFFILIATES, AND TEMPORARY EMPLOYMENT INFORMATION (Completed by Sponsor)

2. NAME OF FIRM OR COMPANY (If applicable)

4. NAME OF RESPONSIBLE VA ORGANIZATION

0711 AdobeFormsDesignerVA FORM

OCT 2006 (RS)

NEW ID RENEWAL REPLACEMENT ID (Damaged/Lost) CHANGE LEVEL OF ACCESS

VA EMPLOYEE CONTRACTOR AFFILIATE (Specify)

YES (If "YES," Specify in Item2)

EMERGENCY RESPONDER

NO NEITHER

Form Approved: OMB No. 2900-0673 Respondent Burden: 5 Minutes

6. HOME E-MAIL ADDRESS (Optional)

1. NAME AND ADDRESS OF FACILITY OR ASSIGNED DUTY STATION 2. NAME OF SPONSORING DEPARTMENT, SERVICE, OR SECTION, AND MAIL ROUTING

SYMBOL

3. CREDENTIALS/ORGANIZATIONAL TITLE (AKA Position/Job Title)

5. WORK PHONE NUMBER (If applicable)

PART B - TYPE OF REQUEST AND EMPLOYMENT STATUS (Completed by Sponsor)

2. TYPE OF CARD

PERSONAL IDENTITY

VERIFICATION (PIV) VA (NON-PIV)

3. NAME OF CONTRACTING OFFICER TECH. REPR. (If applicable)

3. TYPE OF ACCESS

LOGICAL ACCESS PHYSICAL ACCESS (Complete Part D)

TEMPORARY VA EMPLOYMENT

PRIVACY ACT STATEMENT: VA is authorized to ask for the information requested on this form by Homeland Security Presidential Directive (HSPD)-12, and 31 USC 7701. The information and biometrics collected, collected as part of the Federal identity-proofing program under HSPD-12 are used to verify the personal identity of VA applicants for employment, employees, contractors, and affiliates (such as students, WOC employees, and others) prior to issuing a Department identification credential. The credentials themselves are to be used to authenticate electronic access requests from VA employees, contractors, and affiliates issued a Department identification credential to gain access to VA facilities and networks (where available) through digital access control systems, as well as to other federal government agency facilities and systems where permitted by law. The information collected on this form is protected by the Privacy Act, 5 USC Section 552(a) and maintained under the authority of 38 USC Section 501 and 38 USC Sections 901-905 in VA system of records "Police and Security Records-VA (103VA07B)". VA may make a "routine use" disclosure of the information in this system of records for the routine uses listed in this system of records, including: civil or criminal law enforcement, constituent congressional communications initiated at your request, litigation or administrative proceedings in which the United States is a party or has an interest, the administration of VA programs, verification of identity and status, and personnel administration by Federal agencies. Failure to provide all of the requested information may result in VA being unable to process your request for a Personal Identity Verifiction Card, or denial of issuance of a Personal Identity Verification Card. If you do not have a Personal Identity Verification Card, you may not be granted access to VA facilities or networks, which could have an adverse impact on your application to become, or status as, a VA employee, contractor or affiliate where such access is required to perform your assigned duties or responsibilities.

PAPERWORK REDUCTION ACT NOTICE: The public reporting burden is approximately 5 minutes including time to review instruction, find the information, and complete this form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the VA Clearance Officer (005E3), 810 Vermont Avenue, Washington, DC 20420.

4. COST CTR.

5. MAIL ROUTING SYM.

CRITICAL EMPLOYEE

(Domain)

8. SIGNATURE OF APPLICANT 9. DATE SIGNED

PART D - TYPE OF BACKGROUND INVESTIGATION FOR POSITION (Completed by Sponsor)

SAC

TYPE OF BACKGROUND INVESTIGATION FOR POSITION

NACI SECRET TOP SECRET OTHER (Specify)

PART D - REGISTRAR INFORMATION AND SIGNATURE

SECTION III - APPLICANT IDENTITY VERIFICATION (Completed by Registrar)

PART B - PHOTOGRAPHIC IDENTIFICATION NUMBER 1

1. EXACT NAME LISTED ON PHOTO ID 2. DOCUMENT IDENTIFICATION NUMBER 3. EXPIRATION DATE (MM/DD/YYYY)

4. DOCUMENT TYPE 5. ISSUANCE DATE (MM/DD/YYYY) 6. ISSUING AUTHORITY

PART C - IDENTIFICATION NUMBER 2

1. EXACT NAME LISTED ON ID 3. EXPIRATION DATE (MM/DD/YYYY)

5. ISSUANCE DATE (MM/DD/YYYY) 6. ISSUING AUTHORITY

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6. WORK ADDRESS 7. NAME OF SPONSOR'S DEPARTMENT, SERVICE, OR SECTION

8. WORK PHONE NUMBER (Include Area Code)

9. WORK E-MAIL ADDRESS

2. DOCUMENT IDENTIFICATION NUMBER

4. DOCUMENT TYPE

1. WORK ADDRESS 2. PRINTED NAME OF REGISTRAR

3. NAME OF DEPARTMENT, SERVICE, OR SECTION

4. WORK PHONE NUMBER (Include Area Code) 5. WORK E-MAIL ADDRESS

7. APPLICANT'S REQUEST FOR PERSONAL IDENTITY VERIFICATION CARD

ACTION TAKEN:

APPROVED DENIED

CERTIFICATION: I certify that under penalty of perjury that I have examined the documents presented by the above named person, and that the above listed documents appear to be genuine and to relate to the person named.

8. SIGNATURE OF REGISTRAR 9. DATE SIGNED (MM/DD/YYYY)

2. SPONSOR CREDENTIALS/ORGANIZATIONAL TITLE

PART F - SPONSOR AUTHORIZATION AND CERTIFICATION (Completed by Sponsor) CERTIFICATION: I Certify under penalty of perjury that the information in Section II is true and correct.

1. NAME OF SPONSOR

4. SIGNATURE OF SPONSOR 5. DATE SIGNED (MM/DD/YYYY)

INSTRUCTIONS: To be completed and signed by Registrar at the time of proofing. Review Section I - Applicant Information, and Section II - Sponsor Verification, assuring that information has been filled out correctly and signed accordingly. The identification must follow these guidelines:

Applicant must present two (2) forms of identification from the Accepted Identification Documentation List.

One State or Federal ID must contain a photograph.

The names on the identification must match exactly (If one ID has a full middle name, and the other has a middle initial, then the initial must match).

Both IDs must be original documents. Both IDs must be currently valid, not expired.

3. CERTIFICATE NUMBER (Issued by PCI Manager or Registrar)

1A. DATE INITIATED BACKGROUND CHECK

(MM/DD/YYYY)

PART A - BACKGROUND CHECK

1. TYPE OF BACKGROUND CHECK

1B. DATE ADJUDICATED BACKGROUND CHECK

(MM/DD/YYYY)

SAC (Fingerprint Check) NACI OTHER (Specify)

2. FINGERPRINTS CAPTURE REQUIRED?

YES NO (If "NO," proceed to Part B)

3. SEX 4. RACE 5. HEIGHT 6. WEIGHT 7. EYES 8. HAIR 9. PLACE OF BIRTH

10. NOTICABLE SCARS AND TATTOOS

Verify that the applicant has background informaition on file. If no evidence of a SAC exists, then capture fingerprint data and process accordingly.

6. DATE APPLICANT INITIATED BACKGROUND INVESTIGATION

SECTION V - ISSUER (Completed by Issuer)

PART B - PERSONAL IDENTITY VERIFICATION CARD ACCEPTANCE (Completed by Applicant)

I have been provided training on the responsibilities associated with receipt of this Personal Identity Verification Card.

I will use my Personal Identity Verification card in accordance with the training I have been provided.

SECTION IV - PERSONAL IDENTITY VERIFICATION CARD ACCEPTANCE

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ACKNOWLEDGEMENT: I acknowledge receiving my identity credential and will comply with the following obligations:

CERTIFICATION: I certify that I have read and agree to the above statements and that I have received my card.

CERTIFICATION: I certify that I have read and agree to the above statements and that I have received my PKI certificate(s).

1. PRINTED NAME OF APPLICANT 2. APPLICANT SIGNATURE OF ACCEPTANCE

PART A - CARD INFORMATION(Completed by Issuer)

1. NEW PIV CREDENTIAL SERIAL NUMBER 2. OLD ACCESS ID CARD NUMBER 3. EXPIRATION DATE (MM/DD/YYYY)

3. DATE SIGNED (MM/DD/YYYY)

PART C - PUBLIC KEY INFORMATION (PKI) CERTIFICATE ACCEPTANCE (Completed by Applicant)

AUTHORIZATION STATEMENT

You have been authorized to receive one or more private and public key pairs and associated certificates. A private key enables you to digitally sign documents and messages and identify yourself to gain access to information systems and facilities. You may have another private key to decrypt data such as encrypted messages.

People and electronic systems inside and outside VA will use public keys associated with your private keys to verify your digital signature, or to verify your identity when you attempt to authenticate to systems, or to encrypt data sent to you. The certificates and private keys will be issued on a token, for example your Personal Identity Verification Card. The token and the certificates and private keys on your token are government property. Users are authorized to use the certificates within VA, as well as while conducting business with other Federal, state, and Local Government agencies.

ACKNOWLEDGEMENT OF RESPONSIBILITIES

I represent and warrant that the information provided in application for this certificate is accurate, current, and complete. If this information changes, I will notify my Registrar of the changes;

I will use my certificate(s) and private key(s) for official purposes only;

I will comply with the Certificate Practices Statement for selecting a Personal Identification Number (PIN) or other required method for controlling access to my private keys and will not disclose same to anyone, leave it where it might be observed, nor write it on the token itself;

I understand that digital signatures applied using my digital certificates carry the same legal obligation as my physically signing the document;

I understand that if I receive key management (encryption/decryption) key pairs on my token, copies of the private decryption keys have been provided to the key recovery database in case they need to be recovered; and

I will report any compromise (e.g., loss, suspected or known unauthorized use, misplacement, etc.) of my PIN or token to my supervisor, security officer, Certification Authority (CA), or a Registrar, immediately.

LIABILITY

I will have no claim against VA arising from use of the PKI certificates, the key recovery process, or a Certification Authority's (CA) determination to terminate or revoke a certificate. VA is not liable for any loses, including direct or indirect, incidental, consequential, special, or punitive damages, arising out of or relating to any certificate issued by a VA CA.

GOVERNMENT LAW

VA Public Key Certificates shall be governed by the laws of the United States of America.

1. FULL LEGAL NAME OF APPLICANT 2. SIGNATURE OF ACCEPTANCE 3. DATE SIGNED (MM/DD/YYYY)

CERTIFICATION: I certify under penalty of perjury, that I have monitored the identity verification of the person above in accordance with applicable identity proofing processes and have witnessed that person sign this form.

1. WORK ADDRESS 2. PRINTED NAME OF ISSUER

3. NAME OF DEPARTMENT, SERVICE, OR SECTION

4. WORK PHONE NUMBER (Include Area Code) 5. WORK E-MAIL ADDRESS

6. SIGNATURE OF ISSUER 7. DATE SIGNED (MM/DD/YYYY)

.VA Form 0711 Completion Instructions

IMPORTANT: Carefully follow instructions for each section , especially with respect to who completes the section.

Section I- Applicant Information Applicant Information - Completed by Applicant

Item 1 - Enter Applicant's full legal name. (Should match IDs) Item 2 - Enter any Nickname to be used for Applicant. (NOTE: Applies only to new Applicant that does not have an E-mail account) Item 3 - Enter Applicant's date of birth.

Item 4 - Enter Social Security Number.

Item 5 - Enter Applicant's home phone number, including area code.

Item 6 - Enter Applicant's personal home e-mail address.

Item 7 - Enter Applicant's home mailing address.

Item 8 - Applicant Signature.

Item 9 - Date Signed.

Section II - Sponsor Verification - Completed by Sponsor Part A - Applicant Employment Information - Completed by Sponsor

Item 1 - Enter the facility or duty station, name and address, that applicant is assigned to.

Item 2 - Enter name of Sponsoring Department, Service, Section and Mail Routing Symbol.

Item 3 - Enter applicant's position job title Item 4 - Enter cost center.

Item 5 - Enter Applicant's work phone number (As applicable).

Item 6 - Enter work E-mail address.

Part B - Type of Request and Employment Status - Completed by Sponsor

Item 1 - Check applicable box.

Item 2 - Check applicable box based on type of appointment.

Item 3 - Check applicable box. If Logical box is checked, enter Domain name.

Item 4 - Check applicable box.

Part C - Physical Security Access Data - Completed by Sponsor

Item 1 - Check applicable box.

Item 2 - Enter location where access is needed.

Item 3 - Emergency Responder is a person who has completed forty to sixty hours of Department of Transportation approved training in providing care for medical emergencies (otherwise known as a First Responder); Critical Employee is a Designated VA official/employee who requires access to a VA facility during emergency situations.

Part D - Type of Background Investigation for Position Item 1 - Check applicable box.

Part E - Contractors, Affiliates, and Temporary Employment Information - Completed by Sponsor Item 1 - Enter employment expiration date for contractors, affiliates, and temporary employment.

Item 2 - Self Explanatory (As applicable).

Item 3 - Enter full legal name of Contracting Officer's Technical Representative (COTR) (As applicable).

Item 4 - Enter Name of Responsible VA Organization.

Item 5 - Enter Mail Routing Symbol.

Part F - Sponsor Authorization and Certification - Completed by Sponsor

Item 1 - Enter name of sponsor.

Item 2 - Enter Sponsor Credentials and Organizational Title.

Item 3 - Enter Certificate Number which is issued by the Registrar. Contact your Registrar if you do not know the number.

Items 4-9 - Self explanatory.

VA FORM 0711, OCT 2006 (RS)

Section III- Applicant Identity Verification - Completed by Registrar

Picture ID From Federal or State Government Non-Picture ID or Acceptable Picture ID not issued by Fed. or State Gov't

State-Issued Drivers License Social Security Card State DMV-Issued ID Card Certified Birth Certificate U.S. Passport State Voter Registration Card Military ID Card Native American Tribal Document U.S. Coast Guard Merchant Mariner card Certificate of U.S. Citizenship (INS Form N-560 or N-561) Foreign Passport with appropriate stamps Certificate or Naturalization (INS Form N-550 or N-570) Permanent Resident Card or Alien Registration Certification of Birth Abroad Issued by the Department of State Card with a photograph (INS Form I-151/I-551) (Form FS-545 or Form DS-1350) ID Card issued by federal or state government agencies Permanent or Temporary resident card

ID Card issued by local government agencies provided it includes the following information: name, date of birth, gender, height, eye color, and address Non-photo ID Card issued by federal or state government agencies provided it includes the following information: name, date of birth, gender, height, eye color, and address School ID with photograph Canadian Drivers License U.S. Citizen ID Card (Form I-179)

Part A - Background Check - Completed by Registrar

Item 1A - Enter date initiated background check for SAC, NACI, or Other (specify) Item 1B - Enter date adjudicated background check for SAC, NACI, or Other (specify) Item 2 - Check applicable box.

Item 3-9 - Self explanatory Item 10 - Enter all noticable scars and tattoos and other distinguishable features.

Part B - Photographic identification number 1 - Completed by Registrar

Item 1 - Enter the full exact name as seen on the Applicant's ID.

Item 2 - Enter IDs number. (i.e. license number, passport number) Item 3 - Enter date that ID number 1 expires.

Item 4 - Enter the type of ID presented. (i.e. Virginia state issued drivers license) Item 5 - Enter date that the ID was issued to the Applicant.

Item 6 - Enter name issuing ID. (i.e. Department of State, State of Maryland)

Part C - Identification number 2 - Completed by Registrar

Item 1-6 - Same as Part A, only with a second form of an acceptable ID

Part D - Registrar information and signature - Completed by the Registrar

Item 1-5 - Self Explanatory Item 6 - Enter Date applicant inititated background check.

Item 7 - Check appropriate box.

Item 8-9 - Self Explanatory

Section IV- Personal Verification Identity Card Acceptance

Part A - Card Information - Completed by Issuer

Item 1 - Enter new PIV card serial number.

Item 2 - Enter old PIV card serial number (As applicable) Item 3 - Enter expiration date of new PIV card

Part B - Personal Verification Identity Card - Completed by Applicant

Item 1- 3 - Self Explanatory

Part C - Public key information (PKI) certificate acceptance - Completed by Applicant

Item 1 - Enter full legal name of Applicant.

Item 2-3 - Self Explanatory

Section V - Issuer

Item 1-7 - Self Explanatory

6. WORK E-MAIL ADDRESS

4B. SPECIFY SPECIAL SECURITY ACCESS LOCATION (FOR EXAMPLE, TOWER, BUILDING NUMBER, etcetera)

2. NICKNAME TO BE USED FOR APPLICANT (Insert last name and first name, if applicable)

2. NICKNAME TO BE USED FOR APPLICANT (Insert last name and first name, if applicable) PART A - APPLICANT EMPLOYMENT INFORMATION (Completed by Sponsor) PART A - APPLICANT EMPLOYMENT INFORMATION (Completed by Sponsor)

SECTION I - APPLICANT INFORMATION

SECTION 1 - EMPLOYEE INFORMATION

APPLICANT INFORMATION (Completed by Applicant) APPLICANT INFORMATION (Completed by Applicant)

REQUEST FOR PERSONAL IDENTITY VERIFICATION CARD

REQUEST FOR ONE-V.A. IDENTIFICATION CARD

1. LEGAL NAME OF APPLICANT (Insert last , first , middle and suffix name)

1. NAME OF EMPLOYEE (Insert last name, first name, and middle name)

1. LEGAL NAME OF APPLICANT (Insert last , first , middle and suffix name)

4. SOCIAL SECURITY NO.

4. Social Security Number

3. DATE OF BIRTH (MM/DD/YYYY)

3. DATE OF BIRTH (M.M./D.D./Y.Y.Y.Y.)

7. HOME ADDRESS

6. NAME AND ADDRESS OF FACILITY OR ASSIGNED DUTY STATION

5. HOME PHONE NUMBER (Include Area Code) (Optional)

4. EMPLOYMENT STATUS

1. EMPLOYMENT STATUS

1. TYPE OF REQUEST

2. TYPE OF REQUEST (Check only one)

1. SPECIAL SECURITY ACCESS REQUIRED

2. SPECIFY LOCATION OF SPECIAL

SECURITY (i.e. tower, bldg. no., etc.)

4B. SPECIFY SPECIAL SECURITY ACCESS LOCATION (FOR EXAMPLE, TOWER, BUILDING NUMBER, etcetera)

3. IS APPLICANT A KEY EMERGENCY RESPONDER, CRITICAL EMPLOYEE, OR NEITHER?

5. IS APPLICANT A KEY EMERGENCY RESPONDER

PART C - PHYSICAL SECURITY ACCESS DATA (Completed by Sponsor) PART C - PHYSICAL SECURITY ACCESS DATA (Completed by Sponsor)

1. EMPLOYMENT EXPIRATION DATE /CONTRACT END DATE

(MM/DD/YYYY)(For Contractors, Affiliates, and Temporary Employment)

1. EMPLOYMENT EXPIRATION DATE (MM/DD/YYYY) (For Contractor or non-full time VA Employees Only) PART E - CONTRACTORS, AFFILIATES, AND TEMPORARY EMPLOYMENT INFORMATION (Completed by Sponsor) PART E - CONTRACTORS, AFFILIATES, AND TEMPORARY EMPLOYMENT INFORMATION (Completed by Sponsor)

2. NAME OF FIRM OR COMPANY (If applicable)

. NAME OF FIRM OR COMPANY IF CONTRACTOR OR CONSULTANT

4. NAME OF RESPONSIBLE VA ORGANIZATION

5. NAME OF RESPONSIBLE VA ORGANIZATION AND MAIL ROUTING SYMBOL

0711 FORM

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VA FORMOCT 2006 (RS)

V.A. FORM 0711, OCTOBER 2006. OLD STOCK WILL NOT BE USED.

Form Approved: OMB No. 2900-0673 Respondent Burden: 5 Minutes Form Approved: O. M. B. Number 2900-0085 Respondent Burden: 1 Hour

6. HOME E-MAIL ADDRESS (Optional)

9. MS OUTLOOK E-MAIL ADDRESS

1. NAME AND ADDRESS OF FACILITY OR ASSIGNED DUTY STATION

4B. SPECIFY SPECIAL SECURITY ACCESS LOCATION (FOR EXAMPLE, TOWER, BUILDING NUMBER, etcetera)

2. NAME OF SPONSORING DEPARTMENT, SERVICE, OR SECTION, AND MAIL ROUTING

SYMBOL

4B. SPECIFY SPECIAL SECURITY ACCESS LOCATION (FOR EXAMPLE, TOWER, BUILDING NUMBER, etcetera)

3. CREDENTIALS/ORGANIZATIONAL TITLE (AKA Position/Job Title) 4B. SPECIFY SPECIAL SECURITY ACCESS LOCATION (FOR EXAMPLE, TOWER, BUILDING NUMBER, etcetera)

5. WORK PHONE NUMBER (If applicable)

9. MS OUTLOOK E-MAIL ADDRESS

PART B - TYPE OF REQUEST AND EMPLOYMENT STATUS (Completed by Sponsor) PART B - TYPE OF REQUEST AND EMPLOYMENT STATUS (Completed by Sponsor)

2. TYPE OF CARD

2. TYPE OF REQUEST (Check only one)

3. NAME OF CONTRACTING OFFICER TECH. REPR. (If applicable)

2. TYPE OF REQUEST (Check only one)

3. TYPE OF ACCESS

2. TYPE OF REQUEST (Check only one) PRIVACY ACT STATEMENT: VA is authorized to ask for the information requested on this form by Homeland Security Presidential Directive (HSPD)-12, and 31 USC 7701. The information and biometrics collected, collected as part of the Federal identity-proofing program under HSPD-12 are used to verify the personal identity of VA applicants for employment, employees, contractors, and affiliates (such as students, WOC employees, and others) prior to issuing a Department identification credential. The credentials themselves are to be used to authenticate electronic access requests from VA employees, contractors, and affiliates issued a Department identification credential to gain access to VA facilities and networks (where available) through digital access control systems, as well as to other federal government agency facilities and systems where permitted by law. The information collected on this form is protected by the Privacy Act, 5 USC Section 552(a) and maintained under the authority of 38 USC Section 501 and 38 USC Sections 901-905 in VA system of records "Police and Security Records-VA (103VA07B)". VA may make a "routine use" disclosure of the information in this system of records for the routine uses listed in this system of records, including: civil or criminal law enforcement, constituent congressional communications initiated at your request, litigation or administrative proceedings in which the United States is a party or has an interest, the administration of VA programs, verification of identity and status, and personnel administration by Federal agencies. Failure to provide all of the requested information may result in VA being unable to process your request for a Personal Identity Verifiction Card, or denial of issuance of a Personal Identity Verification Card. If you do not have a Personal Identity Verification Card, you may not be granted access to VA facilities or networks, which could have an adverse impact on your application to become, or status as, a VA employee, contractor or affiliate where such access is required to perform your assigned duties or responsibilities.

PAPERWORK REDUCTION ACT NOTICE: The public reporting burden is approximately 5 minutes including time to review instruction, find the information, and complete this form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the VA Clearance Officer (005E3), 810 Vermont Avenue, Washington, DC 20420.

PRIVACY ACT STATEMENT: V.A. is authorized to ask for the information requested on this form by Homeland Security Presidential Directive (H.S.P.D.)-12, and 31 U.S.C. 7701. The information and biometrics collected, collected as part of the Federal identity-proofing program under H.S.P.D.-12 are used to verify the personal identity of V.A. applicants for employment, employees, contractors, and affiliates (such as students, W.O.C. employees, and others) prior to issuing a Department identification credential. The credentials themselves are to be used to authenticate electronic access requests from V.A. employees, contractors, and affiliates issued a Department identification credential to gain access to VA facilities and networks (where available) through digital access control systems, as well as to other federal government agency facilities and systems where permitted by law. The information collected on this form is protected by the Privacy Act, 5 U.S.C. Section 552(a) and maintained under the authority of 38 U.S.C. Section 501 and 38 U.S.C. Sections 901-905 in V.A. system of records "Police and Security Records-V.A. (103V.A.07B)". VA may make a "routine use" disclosure of the information in this system of records for the routine uses listed in this system of records, including: civil or criminal law enforcement, constituent congressional communications initiated at your request, litigation or administrative proceedings in which the United States is a party or has an interest, the administration of V.A. programs, verification of identity and status, and personnel administration by Federal agencies. Failure to provide all of the requested information may result in V.A. being unable to process your request for a Personal Identity Verifiction Card, or denial of issuance of a Personal Identity Verification Card. If you do not have a Personal Identity Verification Card, you may not be granted access to V.A. facilities or networks, which could have an adverse impact on your application to become, or status as, a V.A. employee, contractor or affiliate where such access is required to perform your assigned duties or responsibilities. PAPERWORK REDUCTION ACT NOTICE: The public reporting burden is approximately 5 minutes including time to review instruction, find the information, and complete this form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the V.A. Clearance Officer (005E3), 810 Vermont Avenue, Washington, D.C. 20420.

4. COST CTR.

9. MS OUTLOOK E-MAIL ADDRESS

5. MAIL ROUTING SYM.

9. MS OUTLOOK E-MAIL ADDRESS

(Domain)

8. SIGNATURE OF APPLICANT

4B. SPECIFY SPECIAL SECURITY ACCESS LOCATION (FOR EXAMPLE, TOWER, BUILDING NUMBER, etcetera)

9. DATE SIGNED

4B. SPECIFY SPECIAL SECURITY ACCESS LOCATION (FOR EXAMPLE, TOWER, BUILDING NUMBER, etcetera) PART D - TYPE OF BACKGROUND INVESTIGATION FOR POSITION (Completed by Sponsor)

PART E - CONTRACTORS AND OTHER NON-FULL TIME EMPLOYEES INFORMATION

PART D - TYPE OF BACKGROUND INVESTIGATION FOR POSITION (Completed by Sponsor)

TYPE OF BACKGROUND INVESTIGATION FOR POSITION

PART D - REGISTRAR INFORMATION AND SIGNATURE

PART D - REGISTRAR INFORMATION AND SIGNATURE

SECTION III - APPLICANT IDENTITY VERIFICATION (Completed by Registrar) SECTION III - APPLICANT IDENTITY VERIFICATION (Completed by Registrar)

PART B - PHOTOGRAPHIC IDENTIFICATION NUMBER 1

PART B - PHOTOGRAPHIC IDENTIFICATION NUMBER 1

1. EXACT NAME LISTED ON PHOTO ID

1. EXACT NAME LISTED ON PHOTO IDENTIFICATION

2. DOCUMENT IDENTIFICATION NUMBER

2. DOCUMENT IDENTIFICATION NUMBER

3. EXPIRATION DATE (MM/DD/YYYY)

3. EXPIRATION DATE

4. DOCUMENT TYPE

4. IDENTIFICATION TYPE CODE

5. ISSUANCE DATE (MM/DD/YYYY)

5. ISSUANCE DATE

6. ISSUING AUTHORITY

6. ISSUING AUTHORITY

PART C - IDENTIFICATION NUMBER 2

PART C - IDENTIFICATION NUMBER 2

1. EXACT NAME LISTED ON ID

1. EXACT NAME LISTED ON IDENTIFICATION

3. EXPIRATION DATE (MM/DD/YYYY)

3. EXPIRATION DATE

5. ISSUANCE DATE (MM/DD/YYYY)

5. ISSUANCE DATE

6. ISSUING AUTHORITY

6. ISSUING AUTHORITY

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VA FORM 0711, OCT 2006 (RS), PAGE 2 OF 3

V.A. FORM 0711, October 2006, PAGE 2 OF 3

6. WORK ADDRESS

2. TYPE OF REQUEST (Check only one)

7. NAME OF SPONSOR'S DEPARTMENT, SERVICE, OR SECTION

2. TYPE OF REQUEST (Check only one)

8. WORK PHONE NUMBER (Include Area Code)

2. TYPE OF REQUEST (Check only one)

9. WORK E-MAIL ADDRESS

2. TYPE OF REQUEST (Check only one)

2. DOCUMENT IDENTIFICATION NUMBER

2. DOCUMENT IDENTIFICATION NUMBER

4. DOCUMENT TYPE

4. IDENTIFICATION TYPE CODE

1. WORK ADDRESS

2. TYPE OF REQUEST (Check only one)

2. PRINTED NAME OF REGISTRAR

2. TYPE OF REQUEST (Check only one)

3. NAME OF DEPARTMENT, SERVICE, OR SECTION

2. TYPE OF REQUEST (Check only one)

4. WORK PHONE NUMBER (Include Area Code)

2. TYPE OF REQUEST (Check only one)

5. WORK E-MAIL ADDRESS

2. TYPE OF REQUEST (Check only one)

7. APPLICANT'S REQUEST FOR PERSONAL IDENTITY VERIFICATION CARD

2. TYPE OF REQUEST (Check only one)

ACTION TAKEN:

6. ISSUING AUTHORITY

CERTIFICATION: I certify that under penalty of perjury that I have examined the documents presented by the above named person, and that the above listed documents appear to be genuine and to relate to the person named.

CERTIFICATION: I certify that under penalty of perjury that I have examined the documents presented by the above named person, and that the above listed documents appear to be genuine and to relate to the person named.

8. SIGNATURE OF REGISTRAR

8. SIGNATURE OF REGISTRAR

9. DATE SIGNED (MM/DD/YYYY)

9. DATE SIGNED (M.M./D.D./Y.Y.Y.Y.)

2. SPONSOR CREDENTIALS/ORGANIZATIONAL TITLE

2. TYPE OF REQUEST (Check only one) PART F - SPONSOR AUTHORIZATION AND CERTIFICATION (Completed by Sponsor) PART F - SPONSOR AUTHORIZATION AND CERTIFICATION (Completed by Sponsor) CERTIFICATION: I Certify under penalty of perjury that the information in Section II is true and correct.

CERTIFICATION: I Certify under penalty of perjury that the information in Section 1 is true and correct.

1. NAME OF SPONSOR

2. TYPE OF REQUEST (Check only one)

4. SIGNATURE OF SPONSOR

4. SIGNATURE OF SPONSOR

5. DATE SIGNED (MM/DD/YYYY)

5. DATE SIGNED (MM/DD/YYYY)

INSTRUCTIONS: To be completed and signed by Registrar at the time of proofing. Review Section I - Applicant Information, and Section II - Sponsor Verification, assuring that information has been filled out correctly and signed accordingly. The identification must follow these guidelines:

INSTRUCTIONS: To be completed and signed by Registrar at the time of proofing. Review Section I - Applicant Information, and Section II - Sponsor Verification, assuring that information has been filled out correctly and signed accordingly. The identification must follow these guidelines: Applicant must present two (2) forms of identification from the Accepted Identification Documentation List. The names on the identification must match exactly (If one ID has a full middle name, and the other has a middle initial, then the initial must match). One State or Federal ID must contain a photograph. Both IDs must be original documents. Both IDs must be currently valid, not expired. Verify that the applicant has background informaition on file. If no evidence of a SAC exists, then capture fingerprint data and process accordingly.

Applicant must present two (2) forms of identification from the Accepted Identification Documentation List.

Applicant must present two (2) forms of identification from the Accepted Identification Documentation List.

One State or Federal ID must contain a photograph.

One State or Federal ID must contain a photograph.

The names on the identification must match exactly (If one ID has a full middle name, and the other has a middle initial, then the initial must match).

The names on the identification must match exactly (If one ID has a full middle name, and the other has a middle initial, then the initial must match).

Both IDs must be original documents.

Both IDs must be original documents.

Both IDs must be currently valid, not expired.

Both IDs must be currently valid, not expired.

3. CERTIFICATE NUMBER (Issued by PCI Manager or Registrar)

2. TYPE OF REQUEST (Check only one)

1A. DATE INITIATED BACKGROUND CHECK

(MM/DD/YYYY)

1A. DATE INITIATED BACKGROUND CHECK (MM/DD/YYYY)

PART A - BACKGROUND CHECK

PART A - BACKGROUND CHECK

1. TYPE OF BACKGROUND CHECK

1. TYPE OF BACKGROUND CHECK

1B. DATE ADJUDICATED BACKGROUND CHECK

(MM/DD/YYYY)

1B. DATE ADJUDICATED BACKGROUND CHECK (M.M./D.D./Y.Y.Y.Y.)

SAC (Fingerprint Check)

2. TYPE OF REQUEST (Check only one)

NACI

2. TYPE OF REQUEST (Check only one) OTHER (Specify)

2. TYPE OF REQUEST (Check only one)

2. FINGERPRINTS CAPTURE REQUIRED?

2. TYPE OF REQUEST (Check only one)

3. SEX

2. TYPE OF REQUEST (Check only one)

4. RACE

2. TYPE OF REQUEST (Check only one)

5. HEIGHT

2. TYPE OF REQUEST (Check only one)

6. WEIGHT

2. TYPE OF REQUEST (Check only one)

7. EYES

2. TYPE OF REQUEST (Check only one)

8. HAIR

2. TYPE OF REQUEST (Check only one)

9. PLACE OF BIRTH

2. TYPE OF REQUEST (Check only one)

10. NOTICABLE SCARS AND TATTOOS

2. TYPE OF REQUEST (Check only one) Verify that the applicant has background informaition on file. If no evidence of a SAC exists, then capture fingerprint data and process accordingly.

Verify that the applicant has background informaition on file. If no evidence of a SAC exists, then capture fingerprint data and process accordingly.

6. DATE APPLICANT INITIATED BACKGROUND INVESTIGATION

2. TYPE OF REQUEST (Check only one) SECTION V - ISSUER (Completed by Issuer) SECTION V - ISSUER (Completed by Issuer) PART B - PERSONAL IDENTITY VERIFICATION CARD ACCEPTANCE (Completed by Applicant) PART B - PERSONAL IDENTITY VERIFICATION CARD ACCEPTANCE (Completed by Applicant) I have been provided training on the responsibilities associated with receipt of this Personal Identity Verification Card.

I will use my Personal Identity Verification card in accordance with the training I have been provided.

I have been provided training on the responsibilities associated with receipt of this Personal Identity Verification Card.

I will use my Personal Identity Verification card in accordance with the training I have been provided.

SECTION IV - PERSONAL IDENTITY VERIFICATION CARD ACCEPTANCE

SECTION IV - PERSONAL IDENTITY VERIFICATION CARD ACCEPTANCE

AdobeFormsDesigner Adobe Forms Designer

VA FORM 0711, OCT 2006 (RS), PAGE 3 OF 3

VA FORM 0711, OCT 2006. Old stock cannot be used, PAGE 3 OF 3 ACKNOWLEDGEMENT: I acknowledge receiving my identity credential and will comply with the following obligations:

ACKNOWLEDGEMENT: I acknowledge receiving my identity credential and will comply with the following obligations:

CERTIFICATION: I certify that I have read and agree to the above statements and that I have received my card.

CERTIFICATION: I certify that I have read and agree to the above statements and that I have received my card.

CERTIFICATION: I certify that I have read and agree to the above statements and that I have received my PKI certificate(s).

CERTIFICATION: I certify that I have read and agree to the above statements and that I have received my P.K.I. certificate(s).

1. PRINTED NAME OF APPLICANT

1. PRINTED NAME OF EMPLOYEE

2. APPLICANT SIGNATURE OF ACCEPTANCE

2. APPLICANT SIGNATURE OF ACCEPTANCE

PART A - CARD INFORMATION(Completed by Issuer) PART A - CARD INFORMATION(Completed by Issuer)

1. NEW PIV CREDENTIAL SERIAL NUMBER

1. PRINTED NAME OF EMPLOYEE

2. OLD ACCESS ID CARD NUMBER

1. PRINTED NAME OF EMPLOYEE

3. EXPIRATION DATE (MM/DD/YYYY)

1. PRINTED NAME OF EMPLOYEE

3. DATE SIGNED (MM/DD/YYYY)

3. DATE SIGNED (M.M./D.D./Y.Y.Y.Y.)

PART C - PUBLIC KEY INFORMATION (PKI) CERTIFICATE ACCEPTANCE (Completed by Applicant) PART C - PUBLIC KEY INFORMATION (PKI) CERTIFICATE ACCEPTANCE (Completed by Applicant)

AUTHORIZATION STATEMENT

AUTHORIZATION STATEMENT

You have been authorized to receive one or more private and public key pairs and associated certificates. A private key enables you to digitally sign documents and messages and identify yourself to gain access to information systems and facilities. You may have another private key to decrypt data such as encrypted messages. People and electronic systems inside and outside VA will use public keys associated with your private keys to verify your digital signature, or to verify your identity when you attempt to authenticate to systems, or to encrypt data sent to you. The certificates and private keys will be issued on a token, for example your Personal Identity Verification Card. The token and the certificates and private keys on your token are government property. Users are authorized to use the certificates within VA, as well as while conducting business with other Federal, state, and Local Government agencies.

You have been authorized to receive one or more private and public key pairs and associated certificates. A private key enables you to digitally sign documents and messages and identify yourself to gain access to information systems and facilities. You may have another private key to decrypt data such as encrypted messages. People and electronic systems inside and outside V.A. will use public keys associated with your private keys to verify your digital signature, or to verify your identity when you attempt to authenticate to systems, or to encrypt data sent to you. The certificates and private keys will be issued on a token, for example your Personal Identity Verification Card. The token and the certificates and private keys on your token are government property. Users are authorized to use the certificates within V.A., as well as while conducting business with other Federal, state, and Local Government agencies.

ACKNOWLEDGEMENT OF RESPONSIBILITIES

ACKNOWLEDGEMENT OF RESPONSIBILITIES

I represent and warrant that the information provided in application for this certificate is accurate, current, and complete. If this information changes, I will notify my Registrar of the changes;

I will use my certificate(s) and private key(s) for official purposes only;

I will comply with the Certificate Practices Statement for selecting a Personal Identification Number (PIN) or other required method for controlling access to my private keys and will not disclose same to anyone, leave it where it might be observed, nor write it on the token itself;

I understand that digital signatures applied using my digital certificates carry the same legal obligation as my physically signing the document;

I understand that if I receive key management (encryption/decryption) key pairs on my token, copies of the private decryption keys have been provided to the key recovery database in case they need to be recovered; and

I will report any compromise (e.g., loss, suspected or known unauthorized use, misplacement, etc.) of my PIN or token to my supervisor, security officer, Certification Authority (CA), or a Registrar, immediately.

I represent and warrant that the information provided in application for this certificate is accurate, current, and complete. If this information changes, I will notify my Registrar of the changes; I will use my certificate(s) and private key(s) for official purposes only; I will comply with the Certificate Practices Statement for selecting a Personal Identification Number (P.I.N.) or other required method for controlling access to my private keys and will not disclose same to anyone, leave it where it might be observed, nor write it on the token itself; I understand that digital signatures applied using my digital certificates carry the same legal obligation as my physically signing the document; I understand that if I receive key management (encryption/decryption) key pairs on my token, copies of the private decryption keys have been provided to the key recovery database in case they need to be recovered; and I will report any compromise (For example:, loss, suspected or known unauthorized use, misplacement, etcetera.) of my P.I.N. or token to my supervisor, security officer, Certification Authority (C.A.), or a Registrar, immediately.

LIABILITY

LIABILITY

I will have no claim against VA arising from use of the PKI certificates, the key recovery process, or a Certification Authority's (CA) determination to terminate or revoke a certificate. VA is not liable for any loses, including direct or indirect, incidental, consequential, special, or punitive damages, arising out of or relating to any certificate issued by a VA CA.

I will have no claim against V.A. arising from use of the P.K.I. certificates, the key recovery process, or a Certification Authority's (C.A.) determination to terminate or revoke a certificate. V.A. is not liable for any loses, including direct or indirect, incidental, consequential, special, or punitive damages, arising out of or relating to any certificate issued by a V.A. Certification Authority.

GOVERNMENT LAW

GOVERNMENT LAW

VA Public Key Certificates shall be governed by the laws of the United States of America.

V.A. Public Key Certificates shall be governed by the laws of the United States of America.

1. FULL LEGAL NAME OF APPLICANT

5. ACCEPTANCE SIGNATURE OF LRA DESIGNATE

2. SIGNATURE OF ACCEPTANCE

2. SIGNATURE OF ACCEPTANCE

3. DATE SIGNED (MM/DD/YYYY)

3. DATE SIGNED (M.M./D.D./Y.Y.Y.Y.)

CERTIFICATION: I certify under penalty of perjury, that I have monitored the identity verification of the person above in accordance with applicable identity proofing processes and have witnessed that person sign this form.

CERTIFICATION: I certify under penalty of perjury, that I have monitored the identity verification of the person above in accordance with applicable identity proofing processes and have witnessed that person sign this form.

1. WORK ADDRESS

2. TYPE OF REQUEST (Check only one)

2. PRINTED NAME OF ISSUER

2. TYPE OF REQUEST (Check only one)

3. NAME OF DEPARTMENT, SERVICE, OR SECTION

2. TYPE OF REQUEST (Check only one)

4. WORK PHONE NUMBER (Include Area Code)

2. TYPE OF REQUEST (Check only one)

5. WORK E-MAIL ADDRESS

2. TYPE OF REQUEST (Check only one)

6. SIGNATURE OF ISSUER

6. SIGNATURE OF ISSUER

7. DATE SIGNED (MM/DD/YYYY)

7. DATE SIGNED (M.M./D.D./Y.Y.Y.Y.)

C:\Program Files\Adobe\Form Designer\Forms\Adobe.xft\VA0711.xft David Wachter

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VA0711

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PDFForms.xml Spelling Checker;{224F7DEA-B7C1-11D3-AB40-00902712A5C9};PLSSpeller.cab Request for One-VA Identification Card David Wachter VA Form 0711

FEB 2005

.VA Form 0711 Completion Instructions

IMPORTANT: Carefully follow instructions for each section , especially with respect to who completes the section.

Section I- Applicant Information Applicant Information - Completed by Applicant

Item 1 - Enter Applicant's full legal name. (Should match IDs) Item 2 - Enter any Nickname to be used for Applicant. (NOTE: Applies only to new Applicant that does not have an E-mail account) Item 3 - Enter Applicant's date of birth.

Item 4 - Enter Social Security Number.

Item 5 - Enter Applicant's home phone number, including area code.

Item 6 - Enter Applicant's personal home e-mail address.

Item 7 - Enter Applicant's home mailing address.

Item 8 - Applicant Signature.

Item 9 - Date Signed.

Section II - Sponsor Verification - Completed by Sponsor Part A - Applicant Employment Information - Completed by Sponsor

Item 1 - Enter the facility or duty station, name and address, that applicant is assigned to.

Item 2 - Enter name of Sponsoring Department, Service, Section and Mail Routing Symbol.

Item 3 - Enter applicant's position job title Item 4 - Enter cost center.

Item 5 - Enter Applicant's work phone number (As applicable).

Item 6 - Enter work E-mail address.

Part B - Type of Request and Employment Status - Completed by Sponsor

Item 1 - Check applicable box.

Item 2 - Check applicable box based on type of appointment.

Item 3 - Check applicable box. If Logical box is checked, enter Domain name.

Item 4 - Check applicable box.

Part C - Physical Security Access Data - Completed by Sponsor

Item 1 - Check applicable box.

Item 2 - Enter location where access is needed.

Item 3 - Emergency Responder is a person who has completed forty to sixty hours of Department of Transportation approved training in providing care for medical emergencies (otherwise known as a First Responder); Critical Employee is a Designated VA official/employee who requires access to a VA facility during emergency situations.

Part D - Type of Background Investigation for Position Item 1 - Check applicable box.

Part E - Contractors, Affiliates, and Temporary Employment Information - Completed by Sponsor Item 1 - Enter employment expiration date for contractors, affiliates, and temporary employment.

Item 2 - Self Explanatory (As applicable).

Item 3 - Enter full legal name of Contracting Officer's Technical Representative (COTR) (As applicable).

Item 4 - Enter Name of Responsible VA Organization.

Item 5 - Enter Mail Routing Symbol.

Part F - Sponsor Authorization and Certification - Completed by Sponsor

Item 1 - Enter name of sponsor.

Item 2 - Enter Sponsor Credentials and Organizational Title.

Item 3 - Enter Certificate Number which is issued by the Registrar. Contact your Registrar if you do not know the number.

Items 4-9 - Self explanatory.

VA Form 0711 Completion Instructions IMPORTANT: Carefully follow instructions for each section, especially with respect to who completes the section. Section I- Applicant Information Applicant Information - Completed by Applicant Item 1 - Enter Applicant's full legal name. (Should match IDs) Item 2 - Enter any Nickname to be used for Applicant. (NOTE: Applies only to new Applicant that does not have an E-mail account) Item 3 - Enter Applicant's date of birth. Item 4 - Enter Social Security Number. Item 5 - Enter Applicant's home phone number, including area code. Item 6 - Enter Applicant's personal home e-mail address. Item 7 - Enter Applicant's home mailing address. Item 8 - Applicant Signature. Item 9 - Date Signed Section II - Sponsor Verification - Completed by Sponsor Part A - Applicant Employment Information - Completed by Sponsor Item 1 - Enter the facility or duty station, name and address, that applicant is assigned too. Item 2 - Enter name of Sponsoring Department, Service, Section and Mail Routing Symbol. Item 3 - Enter applicant's position job title. Item 4 - Enter cost center. Item 5 - Enter Applicant's work phone number (As applicable). Item 6 - Enter work E-mail address. Part B - Type of Request and Employment Status - Completed by Sponsor. Item 1 - Check applicable box. Item 2 - Check applicable box based on type of appointment. Item 3 - Check applicable box. If Logical box is checked, enter Domain name. Item 4 - Check applicable box. Part C - Physical Security Access Data - Completed by Sponsor. Item 1 - Check applicable box. Item 2 - Enter location where access is needed. Item 3 - Emergency Responder is a person who has completed forty to sixty hours of Department of Transportation approved training in providing care for medical emergencies (otherwise known as a First Responder); Critical Employee is a Designated VA official/employee who requires access to a V.A. facility during emergency situations. Part D - Type of Background Investigation for Position. Item 1 - Check applicable box. Part E - Contractors, Affiliates, and Temporary Employment Information - Completed by Sponsor. Item 1 - Enter employment expiration date for contractors, affiliates, and temporary employment. Item 2 - Self Explanatory (As applicable). Item 3 - Enter full legal name of Contracting Officer's Technical Representative (C.O.T.R.) (As applicable). Item 4 - Enter Name of Responsible VA Organization. Item 5 - Enter Mail Routing Symbol. Part F - Sponsor Authorization and Certification - Completed by Sponsor. Item 1 - Enter name of sponsor. Item 2 - Enter Sponsor Credentials and Organizational Title. Item 3 - Enter Certificate Number which is issued by the Registrar. Contact your Registrar if you do not know the number. Items 4-9 - Self explanatory

VA FORM 0711, OCT 2006 (RS)

Section III- Applicant Identity Verification - Completed by Registrar

Picture ID From Federal or State Government Non-Picture ID or Acceptable Picture ID not issued by Fed. or State Gov't

State-Issued Drivers License Social Security Card State DMV-Issued ID Card Certified Birth Certificate U.S. Passport State Voter Registration Card Military ID Card Native American Tribal Document U.S. Coast Guard Merchant Mariner card Certificate of U.S. Citizenship (INS Form N-560 or N-561) Foreign Passport with appropriate stamps Certificate or Naturalization (INS Form N-550 or N-570) Permanent Resident Card or Alien Registration Certification of Birth Abroad Issued by the Department of State Card with a photograph (INS Form I-151/I-551) (Form FS-545 or Form DS-1350) ID Card issued by federal or state government agencies Permanent or Temporary resident card ID Card issued by local government agencies provided it includes the following information: name, date of birth, gender, height, eye color, and address Non-photo ID Card issued by federal or state government agencies provided it includes the following information: name, date of birth, gender, height, eye color, and address School ID with photograph Canadian Drivers License U.S. Citizen ID Card (Form I-179)

Part A - Background Check - Completed by Registrar

Item 1A - Enter date initiated background check for SAC, NACI, or Other (specify) Item 1B - Enter date adjudicated background check for SAC, NACI, or Other (specify) Item 2 - Check applicable box.

Item 3-9 - Self explanatory Item 10 - Enter all noticable scars and tattoos and other distinguishable features.

Part B - Photographic identification number 1 - Completed by Registrar

Item 1 - Enter the full exact name as seen on the Applicant's ID.

Item 2 - Enter IDs number. (i.e. license number, passport number) Item 3 - Enter date that ID number 1 expires. Item 4 - Enter the type of ID presented. (i.e. Virginia state issued drivers license) Item 5 - Enter date that the ID was issued to the Applicant.

Item 6 - Enter name issuing ID. (i.e. Department of State, State of Maryland)

Part C - Identification number 2 - Completed by Registrar

Item 1-6 - Same as Part A, only with a second form of an acceptable ID

Part D - Registrar information and signature - Completed by the Registrar

Item 1-5 - Self Explanatory Item 6 - Enter Date applicant inititated background check.

Item 7 - Check appropriate box.

Item 8-9 - Self Explanatory

Section III- Applicant Identity Verification - Completed by Registrar. Picture I.D. From Federal or State Government Non-Picture I.D. or Acceptable Picture I.D. not issued by Federal or State Government, State-Issued Drivers License Social Security Card. State D.M.V.-Issued I.D. Card Certified Birth Certificate. U.S.