Attachment 11A - CAC Processing CVS Registration form.pdf

CVS REGISTRATION REQUEST

This form is for (select only one) ----------> Initial Issuance: 6 Month Reverification:Reissuance:

Last Name: Middle Name:First Name:

Section I: Applicant Data

Cadency Name:

S S N: Date of Birth:

(mm/dd/yyyy)

E-mail Address:

Personnel Category -------> Navy DoD Contractor Volunteer Other Federal Agency (specify):

Card Expiration Date:

(mm/dd/yyyy)

(Include option years. Date not to exceed 3 years or the Contract End Date)

Contract End Date:

(mm/dd/yyyy)

Contract Number:

AUTHORITY: 10 U.S.C. 133 and E.O. 9397 Privacy Act Statement PRINCIPAL PURPOSE(S): Collection of social security numbers and other personal identifiers is used to ensure positive identification of individuals in order to successfully register them as CVS users.

ROUTINE USERS: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use as follows: The "Blanket Routine Uses" set forth at the beginning of OSD's compilation of systems of records notices apply to this system. The Federal, State agencies and private entities, as necessary, on matters relating to securing information during the conduct of official business, utilization review, professional quality assurance, program integrity, civil and criminal litigation, and access to Federal government facilities, computer systems networks, and controlled areas.

DISCLOSURE: Voluntary, however, failure to provide this information will result in failure to register an individual as a CVS user.

Section II: Eligibility Requirements (Select all that apply)

The applicant requires access to multiple DoD facilities or access to multiple non-DoD Federal facilities on behalf of the Department on a recurring basis for a period of 6 months or more (this requirement is applicable to DoD contractors only).

The applicant requires both access to a DoD facility and logon access to DoD networks on site or remotely.

The applicant requires remote access to DoD networks that use only the CAC logon for user authentication.

The applicant requires frequent access to a DoD network to perform volunteer duties (volunteers only).

Note: A requirement for access to a CAC enabled DoD website, without also meeting as least one of the above eligibility requirements, does not qualify a DoD contractor to be issued a CAC.

Section III: Background Vetting (Select all that apply)

Contractors & other eligible Federal/State Personnel

The applicant has completed an FBI fingerprint check with favorable results.

A National Agency Check with Inquiries (NACI) has been submitted to the Office of Personnel Management (OPM).

The applicant possesses a valid NACI

The applicant possesses a DoD-determined NACI equivalent investigation: { Select NACI equivalent investigation here } ------>

Volunteer Personnel

The applicant has completed an FBI fingerprint check with favorable results.

A National Agency Check with Inquiries (NACI) has been submitted to the Office of Personnel Management (OPM).

The applicant possesses a valid NAC

The applicant requires logon access to a DoD network to do their job.

Section IV: Sponsor Responsibilities (Select all boxes to acknowledge compliance)

I (the Sponsor) understand I am responsible for each task listed below:

I will notify the assigned CVS Trusted Agent if there is a change in the applicant's status that results in them no longer being eligible to retain the credential I am sponsoring them for.

I will notify the assigned CVS Trusted Agent if the applicant is terminated or moved from under my sponsorship or organization.

If the applicant leaves, is terminated, or transfers to another service organization, I will retrieve their credential and properly dispose of it by returning it to a RAPIDS ID card issuance facility.

Sponsor's Name: Sponsor's Phone #: Sponsor's Email:

(Include option years)

Date: (mm/dd/yyyy)

CVS REGISTRATION REQUEST

This form is for (select only one) ----------> Section I: Applicant Data (mm/dd/yyyy)

Personnel Category -------> (mm/dd/yyyy)

(Include option years. Date not to exceed 3 years or the Contract End Date) (mm/dd/yyyy) AUTHORITY: 10 U.S.C. 133 and E.O. 9397 Privacy Act Statement PRINCIPAL PURPOSE(S): Collection of social security numbers and other personal identifiers is used to ensure positive identification of individuals in order to successfully register them as CVS users.

ROUTINE USERS: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use as follows: The "Blanket Routine Uses" set forth at the beginning of OSD's compilation of systems of records notices apply to this system. The Federal, State agencies and private entities, as necessary, on matters relating to securing information during the conduct of official business, utilization review, professional quality assurance, program integrity, civil and criminal litigation, and access to Federal government facilities, computer systems networks, and controlled areas.

DISCLOSURE: Voluntary, however, failure to provide this information will result in failure to register an individual as a CVS user.

Section II: Eligibility Requirements (Select all that apply) Note: A requirement for access to a CAC enabled DoD website, without also meeting as least one of the above eligibility requirements, does not qualify a DoD contractor to be issued a CAC.

Section III: Background Vetting (Select all that apply) Contractors & other eligible Federal/State Personnel Volunteer Personnel Section IV: Sponsor Responsibilities (Select all boxes to acknowledge compliance) (Include option years) (mm/dd/yyyy) 8.2.1.3144.1.471865.466429