Attach 2 DN-52 Form Template.pdf

LIMITED ACCESS PASS

AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization to release information about you, then sign and date in ink.

I authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my background investigation, to obtain any information relating to activities from schools, residential management agents, employers, criminal justice agencies, retail business establishments, or other sources of information. This information may include, but is not limited to my academic, residential, achievement, performance, attendance, disciplinary, employment history, and criminal record information.

I understand that, for some sources of information, a separate specific release will be needed, and I may be contacted for such a release at a later date.

I authorize custodians of records and sources of information pertaining to me release such information upon request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary.

I understand that the information released by records custodians and sources of information is for official use by the Federal Government only and in accordance with routine uses found in System of Records Notice Commerce / Dept. 6 Visitor Logs and Permits for Facilities Under Department Control. Information may be re-disclosed by the Government only as authorized by law. The information displayed may be disclosed to you through the Privacy Act (5 U.S.C. § 552a (b)). Furnishing the information required for the issuance of the pass to you is voluntary;

however, failure to furnish the requested information may delay the issuance of the limited access pass and your access to NIST site may be prohibited.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for the duration of the application from the date signed. Providing incorrect information is grounds for removal from NIST facilities and grounds. Finally, this application is invalid without a NIST Federal Employees approval and signature.

Limited access passes must be returned to the issuing office upon expiration of the pass or upon termination of site access privileges.

Limited access pass holders may access the site Monday – Friday, 6:00 am – 7:00 pm.

• Gaithersburg: Submit to Badging Office, Administration Building 101/Room B08 or fax to 301-975-3303

• Boulder: Submit to the Boulder Badge Office, Bldg. 01 Rm. 1207.

Kiss-n-Ride/Family Pass: Issued for one year from the application approval date to family members and/or individuals that are dropping off and/or picking up an individual working on the NIST campus.

Service Provider/Vendor: Issued for one year from the application approval date to individuals that are providing a service to the organization. (Vending machines, cafeteria supplies, waste management, etc.)

Child Care: Issued for one year from the application approval date or when the child is no longer attending the facility to parents/guardians and other individuals authorized access to the Child Care Facility. All requests must be submitted through the Child Care Center.

Alumni: Issued for one year from the application approval date to former NIST/NOAA/NTIA federal employees.

**Construction/Maintenance Contractor: Issued for six months from the application approval date to individuals on an active contract with NIST/ NOAA/NTIA.

The purpose of the Limited Access Pass is to allow individuals that require access to the campus but are not required to be processed through the Office of Security. Public areas only; escort required for non-public areas.

Document Number (DN) 52

(REV. 04-2023)

NIST PR 2401.01 FOR OFFICIAL USE ONLY

Last name (Type or Print Legibly) First name (Type or Print Legibly) Middle name (Type or Print Legibly) If no middle name use "NMN"

Current Street Address Apt. # City State Zip Code

Date of birth (mm/dd/yyyy) Driver’s License Number or State ID Number If no ID use "N/A"

Issuing State or N/A Social Security Number

Citizenship: Please check one

Type of Pass Requested: Please check one

Alumni

*Access is requested to the following facility(ies) under construction prior to acceptance/occupancy by NIST:

*Service Provider Justification - Please identify Company name, Contact Number & written justification for individual(s) for the limited access pass:

NCIC Check Date Initials Badge Issue Date Badge #

THIS DOCUMENT CONTAINS PII: PLEASE USE SECURE METHODS WHEN SUBMITTING

Document Number (DN) 52

(REV. 04-2023)

NIST PR 2401.01

U.S. DEPARTMENT OF COMMERCE

NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

https://inet.nist.gov/eso/services/visitors-guests

FOR OFFICIAL USE ONLY

*US Permanent Resident: Please attach a copy of a valid Permanent Resident Card to application.

**Foreign National / Non-U.S. Citizen: Please attach a copy of valid passport and a completed NIST1260, which must be approved by OSY at least 3 days prior to visiting campus.

AUTHORITY: DAO-207-12 https://inet.nist.gov/eso/services/visitors-guests

U.S. Citizen

U.S. Permanent Resident*

Foreign National / Non-U.S. Citizen**

Service Provider / VendorKiss & Ride / Family Pass

Child Care

Construction / Maintenance

Applicant Signature (Sign in ink) Date Signed (mm/dd/yyyy) Home Telephone Number

COR Name / Sponsor name and ext.

(Federal Employee)

Sponsor's Division

Sponsor's Signature (Federal Employee)

NIST Gaithersburg Campus

• Hand - Carry: Bldg.101, Rm.B08

• Internal Mail Service: MS 1373

• Fax: (301) 975 - 3303

• For encrypted email instructions and questions email at:

badgeoffice@nist.gov

NIST Boulder Campus

• Hand - Carry: Bldg.01, Rm.1207

• For encrypted email instructions and questions email at:

boulderbadge@nist.gov

*Requires the completion of section below

All applicant information must be filled in for completeness.

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