AD-1197fill.pdf

Request for USDA Identification (ID) Badge Privacy Notice: Public Laws 95-113 and 93-579 permit collection of the data requested on this form. The information is used to determine eligibility for the issuance of USDA Identification Badges. The information will be used to identity proof and register applicants as part of the Personal Identity Verification process. Providing this information is voluntary; however, failure to submit this information may result in denial of a USDA Identification Badge.

A. Source Document Confirmation (To be completed by Human Resources)

1. Replacement ID Badge?

2. BI* Application Complete? (required for new cards only) [*"BI" is a generic reference to all investigations for federal employment purposes]

Applicant Information

3. Compliant ID Badge:

Identity Source Document 2 (Attach copy)

B. USDA Identification Badge Request (To be completed by Sponsor)

28. ____________________________________________________________ 29. Date ____/____/_____ PRINTED NAME OF SPONSOR SIGNATURE (mm/dd/yyyy)

C. Issuance Approval (To be completed by Registrar for new USDA ID badges ONLY, after Section A & B are completed)

FBI Fingerprint Check/NAC Results Registrar Information

37. I hereby certify that the information regarding the above applicant is accurate to the best of my knowledge. I hereby this application for USDA Identification Badge issuance.

38. ____________________________________________________________ 39. Date ____/____/_____ PRINTED NAME OF REGISTRAR SIGNATURE (mm/dd/yyyy)

No

14. Name:

Yes

15. Doc. #:

16. Doc Title:

17. Issuer:

18. Doc. Expiration Date (mm/dd/yyyy):

Yes

19. Name:

20. Doc. #:

21. Doc Title:

22. Issuer:

23. Doc. Expiration Date (mm/dd/yyyy):

Federal Employee Law Enforcement/Physical Security Contractor

AffiliatePress Corp Foreign National

I agree to sponsor the above application for a USDA Identification Badge and certify that the information is accurate to the best of my knowledge.

Yes No

Identity Source Document 1 (Attach copy) approve do not approve

24. Name:

25. Phone:

26. Organization:

27. Email:

27a. Access Required:

Sponsor Information

30. Date Completed (mm/dd/yyyy):

31. Successfully adjudicated?

32. Comments:

33. Name:

34. Organization:

35. Phone:

36. Email:

4. Name:

5. Phone:

6. Position:

7. Birth Date (mm/dd/yyyy):

8. Organization:

9. Work Address:

10. City: 11. State: 12. Zipcode:

13. Email:

10. SSN:

3a. Non-Compliant ID Badge: Site Temporary Retiree 3b. Expiration Date (mm/dd/yyyy):

Reason for Replacement:

D. USDA Identification Badge Details (To be completed by Issuer, after Section A, B [and C, if required] is completed)

Badge Information Issuer Information

I hereby acknowledge issuance of a USDA Identification Badge to the applicant identified above based on verification of the applicant's identity and verification of the above Registrar's issuance approval.

47. ____________________________________________________________ 48. Date ____/____/_____ PRINTED NAME OF ISSUER SIGNATURE (mm/dd/yyyy)

E. Applicant Acknowledgement (To be completed by Applicant, after Section D is completed)

I, the Applicant, confirm receipt of the USDA Identification Badge identified above and that the information is accurate to the best of my knowledge.

49. ____________________________________________________________ 50. Date ____/____/_____ PRINTED NAME OF APPLICANT SIGNATURE (mm/dd/yyyy)

Form No. AD-1197 (Sept. 2005) Page 2 of 2 OMB Control #:0505-0022

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 0505-0022. The time required to complete this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions searching existing data sources, gathering and maintaining the data needed and completing and reviewing the form. (e) Agency Requirements.--Each agency that maintains a system of records shall-- (1) maintain in its records only such information about an individual as is relevant and necessary to accomplish a purpose of the agency required to be accomplished by statute or by executive order of the President; (2) collect information to the greatest extent practicable directly from the subject individual when the information may result in adverse determinations about an individual's rights, benefits, and privileges under Federal programs; (3) inform each individual whom it asks to supply information, on the form which it uses to collect the information or on a separate form that can be retained by the individual-- (A) the authority (whether granted by statute, or by executive order of the President) which authorizes the solicitation of the information and whether disclosure of such information is mandatory or voluntary; (B) the principal purpose or purposes for which the information is intended to be used; (C) the routine uses which may be made of the information, as published pursuant to paragraph (4)(D) of this subsection; and (D) the effects on him, if any, of not providing all or any part of the requested information.

PRIVACY ACT ROUTINE USE 1. To the Department of Justice when: (a) the agency or any component thereof, or (b) any employee of the agency In his or her official capacity; or (c) any employee of the agency In his or her Individual capacity where the Department of Justice has agreed to represent the employee; or (d) the UnitedStates Government, is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records by the Department of Justice Is therefore deemed by the agency to be for a purpose that Is compatible with the purpose for which the agency collected the records. 2. To a court or adjudicative body In a proceeding when: (a) the agency or any component thereof, or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee: or (d) the United States Government, is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records. 3. Except as noted in question 24, when a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute, particular program statute, regulation, rule, or order issued pursuant thereto, the relevant records may be disclosed to the appropriate Federal, foreign, State, local, tribal, or other public authority responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, or order. 4. to any source or potential source from which information is requested in the course of an investigation concerning the hiring or retention of an employee or other personnel action, or the issuing or retention of a security clearance, contract, grant, license, or other benefit, to the extent necessary to identify the individual, inform the source of the nature and purpose of the investigation, and to identify the type of information requested. 5. To a Federal, State, local, foreign, tribal, or other public authority the fact that this system of records contains information relevant to the retention of an employee, or the retention of a security clearance, contract, license, grant, or other benefit. The other agency or licensing organization may then make a request supported by written consent of the individual for the entire record if it so chooses. No disclosure will be made unless the information has been determined to be sufficiently reliable to support a referral to another office within the agency or to another Federal agency for criminal, civil, administrative, personnel, or regulatory action. 6. to contractors, grantees, experts, consultants, or volunteers when necessary to perform a function or service related to this record for which they have been engaged. such recipients shall be required to comply with the Privacy Act of 1974, as amended. 7. To the news media or the general public, factual information the disclosure of which would be in the public interest and which would not constitute an unwarranted invasion of personal privacy. 8. To a Federal, State, or local agency, or other appropriate entities or individuals, or through established liaison channels to selected foreign governments, in order to enable an intelligence agency to carry out its responsibilities under the National Security Act of 1947 as amended, the CIA Act of 1949 as amended, Executive Order 12333 or any successor order, applicable national security directives, or classified implementing procedures approved by the Attorney General and promulgated pursuant to such statutes, orders or directives. 9. To a Member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about whom the record Is maintained. 10. To the National Archives and Records Administration for records management inspections conducted under 44 USC 2904 and 2906. 11. To the Office of Management and Budget when necessary to the review of private relief legislation.

43. Name:

44. Organization:

45. Phone:

46. Email:

40. Name on Badge:

41. Badge Identifier:

42. Badge Expiration Date (mm/dd/yyyy):

Personal Identity Verification (PIV) Request for USDA Credential Richard C. Holman D:20060224065952- 05'00' D:20060224065955- 05'00' 1.0 Request for USDA Identification (ID) Badge Privacy Notice: Public Laws 95-113 and 93-579 permit collection of the data requested on this form. The information is used to determine eligibility for the issuance of USDA Identification Badges. The information will be used to identity proof and register applicants as part of the Personal Identity Verification process. Providing this information is voluntary; however, failure to submit this information may result in denial of a USDA Identification Badge.

A. Source Document Confirmation (To be completed by Human Resources)

1. Replacement ID Badge?

2. BI* Application Complete? (required for new cards only) [*"BI" is a generic reference to all investigations for federal employment purposes] Applicant Information

3. Compliant ID Badge:

Identity Source Document 2 (Attach copy)

B. USDA Identification Badge Request (To be completed by Sponsor)

28. ____________________________________________________________ 29. Date ____/____/_____

PRINTED NAME OF SPONSOR

SIGNATURE

(mm/dd/yyyy)

C. Issuance Approval (To be completed by Registrar for new USDA ID badges ONLY, after Section A & B are completed) FBI Fingerprint Check/NAC Results Registrar Information

37. I hereby certify that the information regarding the above applicant is accurate to the best of my knowledge. I hereby this application for USDA Identification Badge issuance.

38. ____________________________________________________________ 39. Date ____/____/_____

PRINTED NAME OF REGISTRAR

SIGNATURE

(mm/dd/yyyy)

I agree to sponsor the above application for a USDA Identification Badge and certify that the information is accurate to the best of my knowledge.

Identity Source Document 1 (Attach copy) Sponsor Information

31. Successfully adjudicated?

3a. Non-Compliant ID Badge:

D. USDA Identification Badge Details (To be completed by Issuer, after Section A, B [and C, if required] is completed) Badge Information Issuer Information I hereby acknowledge issuance of a USDA Identification Badge to the applicant identified above based on verification of the applicant's identity and verification of the above Registrar's issuance approval.

47. ____________________________________________________________ 48. Date ____/____/_____

PRINTED NAME OF ISSUER

SIGNATURE

(mm/dd/yyyy)

E. Applicant Acknowledgement (To be completed by Applicant, after Section D is completed)

I, the Applicant, confirm receipt of the USDA Identification Badge identified above and that the information is accurate to the best of my knowledge.

49. ____________________________________________________________ 50. Date ____/____/_____

PRINTED NAME OF APPLICANT

SIGNATURE

(mm/dd/yyyy) Form No. AD-1197 (Sept. 2005) OMB Control #:0505-0022 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 0505-0022. The time required to complete this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions searching existing data sources, gathering and maintaining the data needed and completing and reviewing the form. (e) Agency Requirements.--Each agency that maintains a system of records shall-- (1) maintain in its records only such information about an individual as is relevant and necessary to accomplish a purpose of the agency required to be accomplished by statute or by executive order of the President; (2) collect information to the greatest extent practicable directly from the subject individual when the information may result in adverse determinations about an individual's rights, benefits, and privileges under Federal programs; (3) inform each individual whom it asks to supply information, on the form which it uses to collect the information or on a separate form that can be retained by the individual-- (A) the authority (whether granted by statute, or by executive order of the President) which authorizes the solicitation of the information and whether disclosure of such information is mandatory or voluntary; (B) the principal purpose or purposes for which the information is intended to be used; (C) the routine uses which may be made of the information, as published pursuant to paragraph (4)(D) of this subsection; and (D) the effects on him, if any, of not providing all or any part of the requested information. PRIVACY ACT ROUTINE USE 1. To the Department of Justice when: (a) the agency or any component thereof, or (b) any employee of the agency In his or her official capacity; or (c) any employee of the agency In his or her Individual capacity where the Department of Justice has agreed to represent the employee; or (d) the UnitedStates Government, is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records by the Department of Justice Is therefore deemed by the agency to be for a purpose that Is compatible with the purpose for which the agency collected the records. 2. To a court or adjudicative body In a proceeding when: (a) the agency or any component thereof, or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee: or (d) the United States Government, is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records. 3. Except as noted in question 24, when a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute, particular program statute, regulation, rule, or order issued pursuant thereto, the relevant records may be disclosed to the appropriate Federal, foreign, State, local, tribal, or other public authority responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, or order. 4. to any source or potential source from which information is requested in the course of an investigation concerning the hiring or retention of an employee or other personnel action, or the issuing or retention of a security clearance, contract, grant, license, or other benefit, to the extent necessary to identify the individual, inform the source of the nature and purpose of the investigation, and to identify the type of information requested. 5. To a Federal, State, local, foreign, tribal, or other public authority the fact that this system of records contains information relevant to the retention of an employee, or the retention of a security clearance, contract, license, grant, or other benefit. The other agency or licensing organization may then make a request supported by written consent of the individual for the entire record if it so chooses. No disclosure will be made unless the information has been determined to be sufficiently reliable to support a referral to another office within the agency or to another Federal agency for criminal, civil, administrative, personnel, or regulatory action. 6. to contractors, grantees, experts, consultants, or volunteers when necessary to perform a function or service related to this record for which they have been engaged. such recipients shall be required to comply with the Privacy Act of 1974, as amended. 7. To the news media or the general public, factual information the disclosure of which would be in the public interest and which would not constitute an unwarranted invasion of personal privacy. 8. To a Federal, State, or local agency, or other appropriate entities or individuals, or through established liaison channels to selected foreign governments, in order to enable an intelligence agency to carry out its responsibilities under the National Security Act of 1947 as amended, the CIA Act of 1949 as amended, Executive Order 12333 or any successor order, applicable national security directives, or classified implementing procedures approved by the Attorney General and promulgated pursuant to such statutes, orders or directives. 9. To a Member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about whom the record Is maintained. 10. To the National Archives and Records Administration for records management inspections conducted under 44 USC 2904 and 2906. 11. To the Office of Management and Budget when necessary to the review of private relief legislation.