Attachment D Appendix A.pdf

OMB 0703-0061 05/31/2024 CUI (when filled in)

SECNAV 5512/1 (MAY 2021) Controlled by: DoN CUI Category: PRVCY

LDC: FEDCON

Page 1 of 3 CUI (when filled in) POC: Rodney Ramseur, rodney.ramseur@navy.mil, 202-433-4281

DEPARTMENT OF THE NAVY LOCAL POPULATION ID CARD/BASE ACCESS PASS REGISTRATION

PRIVACY ACT STATEMENT:

AUTHORITY: 10 U.S.C. 113, Secretary of Defense; DoD Directive 1000.25, DoD Personnel Identity Protection (PIP) Program; DoD Instruction 5200.08, Security of DoD Installations and Resources and the DoD Physical Security Review Board (PSRB); DoD 5200.08-R, Physical Security Program; DoD Directive 5200.27, Acquisition of Information Concerning Persons and Organizations not Affiliated with the Department of Defense (Exception to policy memos); Directive-Type Memorandum (DTM) 09-012, Interim Policy Guidance for DoD Physical Access Control; DTM 14-005, DoD Identity Management Capability Enterprise Services Application (IMESA) Access to FBI National Crime Information Center (NCIC) Files; and E.O. 9397 (SSN), as amended; OPNAVINST 5530.14E, Navy Physical Security and Law Enforcement Program; Marine Corps Order P5530.14, Marine Corps Physical Security Program Manual;

SORNNM05512-2 Badge and Access Control System Records and DMDC 16, Identity Management Engine for Security and Analysis (IMESA): http://dpcld.defense.gov/Privacy/ SORNsIndex

PURPOSE(S): To control physical access to Department of Defense (DoD), Department of the Navy (DON) or U.S. Marine Corps Installations/Units controlled information, installations, facilities, or areas over which DoD, DON, or U.S. Marine Corps has security responsibilities by identifying or verifying an individual through the use of biometric databases and associated data processing/information services for designated populations for purposes of protecting U.S./Coalition/allied government/national security areas of responsibility and information; to issue badges, replace lost badges, and retrieve passes upon separation; to maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/exit times of personnel.

ROUTINE USE(S): To designated contractors, Federal agencies, and foreign governments for the purpose of granting Navy officials access to their facility.

DISCLOSURE: Providing registration information is voluntary. Failure to provide requested information may result in denial of access to benefits, privileges, and DoD installations, facilities and buildings.

IDENTITY PROOFING AND APPLICANT INFORMATION

1. LAST NAME: 2. FIRST NAME: 3. MIDDLE NAME: 4. NAME SUFFIX:

Jr. Sr. I II III IV

5. RACE AMERICAN INDIAN or ALASKA

(Check one or more): NATIVE ASIAN BLACK or AFRICAN AMERICAN

NATIVE HAWAIIAN

HISPANIC OR LATINO OR OTHER PACIFIC

ISLANDER

WHITE

6. GENDER

(Check MALE FEMALE one):

7. DATE OF BIRTH: 8. CITY OF BIRTH: 9. STATE OF BIRTH: 10. BIRTH COUNTRY:

11. US CITIZEN (Check): YES NO 12. DUAL CITIZENSHIP: YES NO CITIZENSHIP IF OTHER THAN US (Country) :

U.S. Citizen Minimum Documentation Required:

By Birth - Social Security No and/or State ID/Drivers License.

Naturalized - Certification Number, Petition Number, Date, Place and Court, United States passport number, Social Security No and/or State ID/Drivers License.

Derived - Parent's certification number, Social Security No and/or State ID/Drivers License.

Alien Minimum Documentation Required:

Registration Number, Expiration date, Date of entry, Port of entry.

13. IDENTITY SOURCE

DOCUMENTS PRESENTED:

14. DOCUMENT

NUMBER:

15. ISSUED BY

STATE/COURT:

16. ISSUED BY

COUNTRY:

17. ISSUED: 18. EXPIRES:

Social Security No.

United States

State ID/Drivers License United States

Passport No.

Certification Number and Petition Number

Derived - Parent's Certification Number:

Alien Registration No.

Date of Entry: Port of Entry:

OTHER APPROVED IDENTITY SOURCE DOCUMENTS:

19. WEIGHT

(Pounds):

20. HEIGHT

(Inches):

21. HAIR COLOR (Check one):

Blond Brown Black Gray Red

White Silver Auburn Bald

22. EYE COLOR (Check one):

Brown Green Blue

Hazel

Black Gray Violet Unknown

23. HOME ADDRESS (Include city, state, zip code): HOME PHONE (Include Area Code):

24. BASE SPONSOR'S NAME: SPONSOR PHONE (Include Area Code):

Ellen Gallagher (202) 805-9088 mailto:rodney.ramseur@navy.mil http://dpcld.defense.gov/Privacy/

OMB 0703-0061 05/31/2024 CUI (when filled in)

SECNAV 5512/1 (MAY 2021) Controlled by: DoN CUI Category: PRVCY

LDC: FEDCON

Page 2 of 3 CUI (when filled in) POC: Rodney Ramseur, rodney.ramseur@navy.mil, 202-433-4281

EMPLOYMENT ACTIVITY INFORMATON

25. EMPLOYER NAME AND ADDRESS (Include city/state/zip code): EMPLOYER PHONE (Include Area Code):

26. SUPERVISOR NAME AND ADDRESS (Include city/state/zip code): SUPERVISOR PHONE(Include Area Code):

27. Check the applicable box for WORK HOURS box or check the OTHER box and enter the work hours, then check the applicable box for WORK DAYS:

WORK HOURS: 0600-1800 0800-1700 OTHER WORK DAYS: SN M T W TH F ST

PRIOR FELONY CONVICTIONS

28. Have you ever been convicted of a Felony? YES NO Initial

REQUIREMENT TO RETURN LOCAL POPULATION ID CARD

29. I understand that I am required to return my Local Population Identification Card to the Base Pass Office when it expires or if my employment is terminated for any reason. (initial)

AUTHORIZATION AND RELEASE AND CERTIFICATION

30. I hereby authorize the DOD/DON and other authorized Federal agencies to obtain any information required from the Federal government and/or state agencies, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense Security Service (DSS), the U.S. Department of Homeland Security (DHS).

I have been notified of DON right to perform minimal vetting and fitness determination as a condition of access to DON installation/facilities. I understand that I may request a record identifier; the source of the record and that I may obtain records from the State Law Enforcement Office as may be available to me under the law. I also understand that this information will be treated as privileged and confidential information.

I release any individual, including records custodians, any component of the U.S. Government or the individual State Criminal History Repository supplying information, from all liability for damages that may result on account of compliance, or any attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD RESULT IN FINES AND/OR IMPRISONMENT UP TO FIVE YEARS.

BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE YOU HAVE ANSWERED ALL QUESTIONS FULLY AND CORRECTLY.

I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE BY ME ON THIS FORM ARE TRUE, COMPLETE AND CORRECT.

DATE SIGNATURE

FINAL DETERMINATION ON YOUR ACCESS: The Base Commanding Officer has final authority for determination on granting physical access to DON controlled installations/facilities under his/her jurisdiction.

BELOW COMPLETED BY BASE REGISTRAR PERSON CONDUCTING IDENTY PROOFING and NCIC CHECK

31. INFORMATION VERIFIED BY: 32. ENTERED IN C/S SYSTEM BY: 33. PASS ISSUE DATE: 34. PASS EXPIRATION DATE:

35. NCIC CHECK PERFORMED BY: 36. RESULTS OF NCIC CHECK:

NO RECORDS RECORD IDENTIFIER

RECORD NUMBER:

37. RESULTS OF LOCAL RECORDS CHECK:

NO RECORDS RECORD IDENTIFIER

RECORD NUMBER:

Office of Under Secretary of Defense Directive-Type Memorandum (DTM) 09-012, "Interim Policy Guidance for DoD Physical Access Control," December 8, 2009. DTM 09-012 requires that DoD installation government representatives query the National Crime Information Center (NCIC) and Terrorist Screening Database to vet the claimed identity and to determine the fitness of non-federal government and non-DoD-issued card holders (i.e.

visitors) who are requesting unescorted access to a DoD installation. The minimum criteria to determine the fitness of a visitor is: 1) not on a terrorist watch list; 2) not on an DoD installation debarment list; and 3) not on a FBI National Criminal Information Center (NCIC) felony wants and warrants list.

Additionally, SECNAV Memo, Policy for Sex Offender Tracking and Assignment and Access Restrictions within the Department of the Navy, of 7 Oct 08 and OPNAVINST 1752.3 established the Navy's policy on sex offenders, requiring Region Commanders (REGCOMs) and Installation Commanding Officers (COs) to prohibit sex offender access to DoN facilities and Navy owned, leased or PPV housing. This form describes the authority and purpose to collect and share the required information; and identifies the applicant/visitor and sponsor; and authorizes the DoD to perform the minimum vetting and fitness determination criteria. A favorable response on the vetting and fitness determination is required to receive access to DOD-controlled installation/facilities.

mailto:rodney.ramseur@navy.mil