Attachment 11 TE 10 INSTALLATION ACCESS BADGE SECNAV FORM 5512-1.pdf

BADGE/IDENTIFICATION CARD APPLICATION

**FEDERAL IDENTIFICATION ACT** Badge issued for use of the person designated hereon. Use or possession by any other person is unlawful and makes the offender liable to penalty, 18 USC 499, 506, AND 701.

AP

PL

IC

AN

T

SECTION A – PERSONAL DATA – (Please Print All Information)

1. NAME (Last, First, Middle): 2. SSN: 3. DATE OF BIRTH:

4. CITIZENSHIP

Other (Specify)

5. LOCAL ADDRESS: 6. HOME PHONE:

7. APPLICANT’S

DESCRIPTION

c. HAIR COLOR: d. EYE COLOR:

EM

PL

O

YE

R/

SP

O N

SO

R

8. POSITION TITLE: 9. RATE/RANK: 10. EMPLOYMENT STATUS:

12. WORK PHONE:

14. CONTRACT TYPE: (If Subcontractor, list Prime Contractor) Prime Sub

18. JUSTIFICATION / AREAS REQUESTED: (Why is access required?)

19. . ESSENTIAL PERSONNEL 20. EMERGENCY OPERATIONS CENTER AUTHORIZING OFFICIAL SIGNATURE

21. REQUESTING OFFICIAL’S SIGNATURE (Authorization & Specimen Signature must be on file.)

AP

PR

O

VI

N G

O

FF

IC

IA

LS

22.a. CSG10

Approved Area(s)

(AREAS 1,2) b. CSG 10 APPROVING OFFICIAL’S SIGNATURE c. ESCORT

1 2

d. DATE

23.a. CSS 20/NSSC

Approved Area

(AREA 3)

b. CSS 20/NSSC APPROVING OFFICIAL’S SIGNATURE c. ESCORT

d. DATE

24.a. SWFLANT

Approved Area(s)

(AREAS 4,5,6)

4 5 6

b. SWFLANT SECURITY APPROVING OFFICIAL’S SIGNATURE c. ESCORT

4 5 6

d. DATE

25.a. TRIREFFAC

Approved Area(s)

(AREAS 7,8,9)

7 8 9

b. TRF APPROVING OFFICIAL’S SIGNATURE c. ESCORT

7 8 9

d. DATE

26.a. PORT OPERATIONS (AREA 10)

Approved Area 10

b. SUBASE SECURITY APPROVING OFFICIAL’S SIGNATURE c. ESCORT

d. DATE

27.a. MCSFCO

Approved Area

(AREA 11)

b. MCSFBN SECURITY APPROVING OFFICIAL’S SIGNATURE c. ESCORT

d. DATE

28.a. BASE CONT AREA (BCA) (AREA 12)

Approved Area(s) BCA 12

b. SUBASE SECURITY APPROVING OFFICIAL’S SIGNATURE c. ESCORT

d. DATE

PA

SS

ID

SECTION D – BADGE INFORMATION

29. BADGE TYPE: 30. BADGE NO: 31. DATE ISSUED: 32. EXPIRATION DATE:

33. SIGNATURE OF RECEIPT (Applicant): 34. DATE RECEIVED:

PRIVACY ACT DATA

AUTHORITY: This information is provided pursuant to USC 352.a.

PURPOSE & USE: The purpose of this form is to maintain a record system of identification badges issued to individuals being allowed ready access to SUBASE Kings Bay. Routine use of this form is for the maintenance of information regarding individuals to whom identification badges have been issued.

DISCLOSURE: Voluntary, however, if information is not provided individual will not be issued an identification badge affording access to SUBASE Kings Bay.

SUBASE KINGS BAY 5512/01 (REV. 5-21)

Temp. Civil Service Construction Cont.Perm. Civil Service Military

Vendor Resident Contractor

1 2

NAFI

Other

U.S.

a. HEIGHT (Inches): b. WEIGHT:

SECTION B – EMPLOYMENT DATA

11. EMPLOYER (SUBASE Department, Tenant Command, Company):

13. CONTRACT NUMBER: 15. CONTRACT EXPIRATION DATE:

SECTION C – ACCESS REQUIRED/REASON

16 a. CLEARANCE LEVEL (Optional): 16 b. NCIC FAVORABLE DATE: 17. BADGE EXPIRATION DATE:

Escort Duties and Responsibilities Acknowledgement Statement

The following policy and procedures apply to Restricted Area escorts. Escorts must be DoD personnel or contractor employees, and may escort more than one visitor, but only one vehicle unless vehicles are in a convoy. Escorts are physically assigned to each visitor and must understand their duties and responsibilities. If additional escorts are required, the original escort will ensure each escort understands their escort duties and responsibilities. Escorts will ensure all escortees have a current and valid identification badge. The original escort is the sole accountable party during the entire time the visitor is within the Restricted Area.

1. Escorts will meet their visitor at Pass & ID office or other suitable location and escort the visitor directly to the designated workplace.

2. Escorts will clearly identify and brief the visitor on the buildings, specific rooms, and location of the area to be visited.

3. Escorts will advise the visitor that unescorted movement outside the designated workplace will result in termination of the visit.

4. Visitors must be accompanied 100 percent of the time, except during restroom breaks, at which time the escort will wait outside of the restroom facility.

5. Escorts will supervise the visitors throughout the visit and ensure they do not wander into areas and spaces where they are not authorized.

6. When the escort has been physically separated from the visitor, or in case of doubt, the escort must immediately report it to SUBASE Security Dispatch (X911) or Waterfront Dispatch (912-573-9902/0101) inside the WRA.

7. When accessing a Restricted Area, the escort must precede the visitor into the area and egress last when departing the area.

8. Act as a point of contact between the visitor and other local command entities when required.

9. Alert emergency services, as appropriate, in the event of an accident/incident involving the visitor.

10. Provide direction for the visitor in the event of an emergency or casualty within the area visited.

11. At the end of each visit, escorts will accompany the visitor to Pass & ID office or other suitable location.

12. Ensure visitors are aware of prohibited items list if entering the WRA.

I have read and understand the requirements stated herein. I also understand that failure to comply with the provisions set forth above may be grounds for termination of escort privileges.

Date/Time: Escort Name:

Escort Signature: