Attachment J-3 PIV_Request_Form.pdf

Court Services and Offender Supervision Agency Personal Identity Verification (PIV) Request Form

Upon Completion, return this form to the Registrar

Section I. PIV Request & Source Documentation (To be completed by Sponsor)

1. New Card? � Yes � No Replacement Card? � Yes � No 1a. Reason for Replacement____________________________________

Applicant Information Type � Employee � Contractor � Guest/Other

2. Name (Last, First, Middle): ________________________________________

3. Applicant ID Number (or SSN):________________________

4. DOB/POB:_________________________________________________

5. Organization/Title:___________________________________________________

6. Work Phone:_______________________________

I agree to sponsor the above Applicant for a PIV card and certify that all information provided is accurate to the best of my knowledge.

7. Sponsor / Enrollment Official Signature: ______________________________________________ 8. Date: ________________________

9. Sponsor/Enrollment Official printed Name and Telephone Number: _____________________________________________________

Section II. Card Approval and Identity Proofing (To be completed by Registrar)

10. NAC / Background Investigation / FBI Fingerprint Check Result (Circle one)

Favorable? � Yes � No (If no, notify Sponsor for adjudication decision)

11 Comments___________________________________________________

Card issuance � Approved � Disapproved

12. Access Level:: ____________________________________________________

13. Did Applicant present two forms of identification, one of which was a photo ID issued by a state or the Federal Government?

� Yes � No

14. Copies of Source Documents attached? � Yes � No

I certify that the above applicant appeared before me and presented two ID source documents in compliance with HSPD-12, which appeared to be genuine.

15. Registrar Signature: ________________________________________ 16. Date:____________________________

Section III. Card Details (To be completed by the Issuer, after Section II is completed)

17. Name on Card Is the Same as Name Above � Yes � No

18. PIV Card Number______________________________________________

19. Card expiration date:____________________________________________

A PIV card was issued to the Applicant identified above base on verification of the Applicant’s identity and the above Registrar’s approval.

At time of issue, applicant presented one photo ID, issued by a state or the Federal Government.

20. Issuer Official Signature: ________________________________________ 21. Date:____________________________

Section IV. Applicant Acknowledgement (To be completed by the Applicant, after Section III is completed) I confirm receipt of the PIV card identified above, verify that the information is accurate to the best of my knowledge, and agree to abide by all rules and responsibilities associated with this card as follows:

A. SAFEGUARDING: I accept responsibility for safeguarding the proximity/identification card issued to me. When I am not wearing the card or the card is not in my physical custody, I will secure it against loss or theft in the same or similar manner, as I would protect my purse or wallet against loss or theft.

B. USE: I will use the card for official purposes only and will not loan, give, or otherwise allow any other person to use my card for any purpose. I will use the card only for official identification.

C. COUNTERFEITING: I will not attempt to clone, modify, or obtain data from any proximity/identification card D. WEARING/DISPLAYING: When required, I will prominently display the front (photo side) of the card at all times within the workplace, and elsewhere as required. When displaying the card, it will be worn between the neck and waist, on the front of the wearer.

E. REPORTING LOSS OR THEFT: I will immediately report any loss or theft of the card to the Office of Security, Room 820, 633 Indiana Avenue (Tel: 220-5750). If I subsequently recover my lost or stolen card, I will promptly return it to the Security Staff.

F. RETURN OF CARD: I will immediately return the card to the Security Staff when my employment with the CSOSA or PSA is terminated, or upon a request by the appropriate authority.

22. Applicant Signature: _______________________________________________________ 23. Date:____________________________

Procurement Use Only (Fill Out Below Information) Contract Expiration Date: _________________________

Contract/Purchase Order No._______________________

Name (Printed)__________________________________

Signature____________________________________

Issuer Information Issuer Org/Phone Office of Security/220-5750

Name (Printed)__________________________________

Registrar Information Security Org/Phone Office of Security/220-5750

Name (Printed)__________________________________