Section L Appendix 6 Badging Request Form (Includes TAA).docx

Badging Request

Name (First, Middle, Last) *Please specify if no middle name (NMN)

SSN

Date of Birth

Place of Birth (City, State, or Country)

Country of Citizenship

Naturalization Number *Must submit scanned copy of Naturalization Certificate or U.S. Passport with request

Legal Permanent Resident (LPR) Card Number *Must submit scanned copy of LPR card with request

LPR Expiration Date

Employee’s Home Address *Include City, State, and Zip Code

Date(s) of Visit *Must include start date and end date

Agreement Number

Position Title

Driver’s License Number *Must submit a scanned copy with request Issuing State

E-mail Address

Home Phone (Include Area Code)

Cell Phone (Include Area Code)

Company Name/Mailing Address/Phone Number

Is IT Access Required (Y/N) – Please be specific *Requires access to KSC system (i.e. SharePoint, internal Web sites, or applications)

Justification for IT Access – What role/work requires the request for IT access?

Is Temporary Area Access (TAA) needed? (Y/N)

Escorted or Unescorted TAA?

Area(s) to be Accessed (Provide Area Number[s])

Purpose for Access (Detailed)

Date(s) of Access