Credentialing_Application_for_GSA_NCR_HSPD-12.pdf

CREDENTIALING APPLICATION FOR Revised 8/06/08 GSA NATIONAL CAPITAL REGION - HSPD-12 Federal ID Application Form

Office phone 202-205-2523 – Fax 202 260-5097 – Hours of Operation 8:00AM to 12:00am and 1:00pm to 4:00 Location: GSA NCR 7th Street. SW, Room 5052 Washington DC 20407

APPLICATANT INFORMATION

Applicant Name:______________________________ Last, First, MI (Please Print Legibly)

Position Title: ________________________________________________

(Required) Contract # ___________________________________________________

(If Contractor) Company Name: _______________________________________________

Address: _____________________________________________________

Telephone Number: (________) _______________________

CONTRACT EXPIRATION DATE _____/______/________

MM DD YYYY

Social Security Number:

DOB: ____________/_____________/_____________

MM DD YYYY

PLACE OF BIRTH (City, State):

Applicant Signature and Date:

Signature

Date: _____________

Applicants GSA Office Correspondence Symbol: _____GS Grade______

(Required) Email address : __________________________________________________

(Applicant’s individual email address. Be sure it is accurate)

Office Address: _______________________________________

Building I.D #/ Name:_____________________________________ Room Number______________________

City: ____________________State: __________Zip Code_____________

Telephone: (_____)_____________________

Applicant Home Address:

Street: ______________________________________

City: _______________________________________

State: __________________Zip Code: ____________ Telephone Number: (_____)_____________________

Gender_______ Hair Color: ______________ Eye Color: ____________ Height: _____________ Citizenship: _______________

GSA APPROVING OFFICIAL/SUPERVISOR (SECURITY USE ONLY)

Emergency Responder Code:

None Federal Emergency Response Official Federal Fire Protection Official

GSA Specific Codes:

None Law Enforcement Carrying Firearm

FBI Fingerprints complete? Y or N

NACI complete: Y or N If Yes, Date Completed: _______________

NACI In progress? Y or N If yes, Date Submitted: _________________

Input Date: ________/________/_______ Processed by: _______________________

By signing this form, you are confirming that the above individual is an employee of or contracted by GSA.

Name (print):_____________________________________

Signature: _______________________________________

Date:____________________________________________

Telephone Number:________________________________

PRIVACY ACT STATEMENT:

In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information is authorized by the Federal Property and Administrative Services Act of 1949, as amended, and Part III of Title 5, U.S.C; O. 9397 Disclosure of the information is voluntary. This form will be used as a means to prepare and issue a credential or pass.

Information will be transferred to appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal or regulatory investigations or prosecutions, or pursuant to a request by GSA or such other agency in connection with the firing or retention of an employee, the issuance of a security clearance, the investigation of an employee, the letting of a contract, or the issuance of a license, grant, or other benefit. If the individual does not provide some or any part of the requested information, the employee will not be issued a credential and will not be allowed to enter a GSA-controlled building after normal working hours or when the building is under security.