A12 Badge Request 45 SFS Form V14.pdf

45 SFS CREDENTIAL REQUEST FORM

(SUBJECT TO THE PRIVACY ACT OF 1974)

PRIVACY ACT STATEMENT

AUTHORITY: E.O. 9397; The Privacy Act of 1974, 5 U.S.C. 522a; DODD 8500.1

PRINCIPAL PURPOSE(S): To provide necessary information to determine if applicant meets installation access control requirements IAW HSPD12, DoD 5200.8, DTM 09-12, FIPS201 and AFMAN 31-113. Use of SSN is necessary to make positive identification of an applicant. Records in the Defense Biometric Identification System (DBIDS) are maintained to support DoD physical security and information assurance programs and are used for identity verification purposes, to record personal property registered with the DoD and for producing facility management reports. SSN, Driver’s License Number or other acceptable identification will be used to distinguish individuals who request access to SLD 45 property.

DISCLOSURE: Voluntary. However, failure to provide the requested information may result in denial of an access credential and denial of access to SLD 45 property

REQUIRES ACCESS TO:

Patrick SFB Cape Canaveral SFS VSFB

LONG TERM

(60 days or more)

SHORT TERM

(59 days or less)

TYPE

Govt Employee Govt Contractor Visitor Volunteer Student Caretaker Housing

I. VISITOR’S INFORMATION

NAME(First, Middle Initial, Last) BIRTH(MM/DD/YYYY) SOCIAL SECURITY NUMBER

DRIVER’S LICENSE NUMBER STATE COMPANY/UNIT

US CITIZEN? ALIEN/PASSPORT NUMBER/COUNTRY OF

BIRTH(non-US Citizens)

GENDER HEIGHT(ft/In) WEIGHT(lbs) EYE COLOR HAIR COLOR

YES NO

Does Applicant have a valid Federally Issued Common Access Card (CaC)? YES NO

Contract end date/ Contract number (if applicable)

II. ORGANIZATION/SPONSOR AND ACCESS DATES/TIMES

START DATE(MM/DD/YYYY) DAYS REQUESTING ACCESS

Hours (e.g.

0730- 1630)

MON TUE WED THU FRI SAT SUN

END DATE(MM/DD/YYYY)

REQUESTOR/SPONSOR AGENCY/ORGANIZATION DUTY PHONE

BADGING OFFICIAL/SPONSOR SIGNATURE DATE

REMARKS

III. Security and Safety Training (CCSFS ONLY)

Scan the QR Code to access/complete the training and answer the questions.

TRAINING COMPLETED (MM/DD/YYYY): ___________________________________

Dial 911 (853-0911 cell phone) to report any emergency.

IV. ACKNOWLEDGEMENT OF INSTALLATION DRIVING PROCEDURES: INITIALS

V. 45 SFS USE ONLY

ON SRBW DATE OF NCIC CHECK NCIC OPERATOR COMMENTS

YES NO

PERMANENT RESIDENT (GREEN CARD HOLDER)

YES NO

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INSTRUCTIONS FOR COMPLETING CREDENTIAL REQUEST FORM (Must be typed or printed clearly in ink).

Directions for Submitting:

CCSFS: Page one (1) of this form may be: 1) hand delivered by the badging official, 2) faxed to the CCSFS Visitor Center at (321) 853-3441 or 3) emailed to 45sfs.s5v.ccafsvcc@us.af.mil. Allow three (3) duty days for processing.

PSFB: Page one (1) of this form must be emailed to 45sfs.s5.vcc@spaceforce.mil. Allow three (3) duty days for processing.

Credential Type: Select either Patrick SFB and/or Cape Canaveral Space Force Station for installation access. VSFB may be selected for those organizations with work centers at both Cape Canaveral SFS and Vandenberg SFB. Check long term (60 days or more) or short term paper pass (59 days or fewer). Check reason (e.g. Employee, Contractor, Visitor, Volunteer, Housing).

I. Visitor’s Information:

Name – Enter individual’s legal first name, middle initial and last name. (Mandatory) Birth – Date of Birth using MM/DD/YYYY format. (Mandatory) Social Security Number – Enter the individual’s social security number. (Mandatory) Drivers License/State – Enter individuals complete driver’s license number and state issued. (Highly recommended) Company/Unit - Name US Citizen – Check either Yes or No if the individual is a US citizen. (Mandatory) Alien Passport – Used to document Alien, Passport or immigration number of non-US citizens Gender – Enter either M or F Height – Enter height of individual in feet and inches, e.g. 5’8” Weight – Enter weight in pounds, e.g. 175 Eye Color – Enter individual’s eye color, e.g. Black, Blue, Gray, Green, Hazel, Violet Hair Color – Individual’s hair color, e.g. Auburn, Black, Blond, Gray, Red, Silver, White Federal issued Common Access Card (CAC) -- Select Yes or No

II. Sponsoring Organization and Access Date/Times (Completed by Sponsor):

Start Date - Enter date the card/visitor pass is to become effect. (Mandatory) End Date – The date which the card/visitor pass expires. (Mandatory) Days Requesting Access – Enter time(s) for authorized access for each day. Leave blank for default DBIDS access 24x7.

Requestor /Sponsor– Enter name of person completing access request form. (Mandatory) Agency/Organization – Enter requestor’s organization (Mandatory) Duty Phone – Enter requestor’s duty phone.

Signature/Date – Requestor’s signature and date. (Mandatory) Remarks – Enter any additional processing instructions

III. Security and Safety Training (CCSFS ONLY): Complete training and completion date entered. (Mandatory)

IV. Acknowledgement of Installation Driving Procedure’s (IAW DAFI 31-218, Motor Vehicle Traffic Supervision and DAFI 91-207, The Traffic Safety Program):

Personnel will comply with all rules and regulations while operating a vehicle within the jurisdiction of Patrick SFB/Cape Canaveral SFS.

Failure to comply with established procedures may result in revocation of driving privileges.

- Personnel and their property are subject to search at any time

- Seatbelts must be worn at all times

- Texting while operating a motor vehicle is prohibited

- Talking on a cellular phone while operating a motor vehicle is prohibited unless using hands free technology.

V. 45 SFS use only: Internal use only.

mailto:45sfs.s5v.ccafsvcc@us.af.mil mailto:45sfs.s5.vcc@spaceforce.mil