B-2 Attach 4 DN52 Form Template.pdf

FOR OFFICIAL USE ONLY

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 one (1) year 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 Visitors Center or fax to 303-497-7402 or 303-497-6370

Kiss-n-Ride/Family Pass: Issued for one year duration 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 duration to individuals that are providing a service to the organization. (Vending machines, cafeteria supplies, waste management, etc.)

Child Care: Issued for one year duration or when the child is no longer attending the facility to parents/guardians and other individuals authorized access to the Child Care Facility.

Alumni: Issued for one year to former NIST/NOAA/NTIA federal employees.

**Construction/Maintenance Contractor: Issued for six months 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. 06-2020)

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)

Current Street Address Apt. # City State Zip Code

Date of birth (mm/dd/yyyy) Driver’s License Number Issuing State Social Security Number

Are you a US Citizen?

Yes

No*

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

*Non-US Citizens: Please attach a copy of a 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

Type of Pass Requested: Please circle one

Kiss & Ride/Family pass

Child Care

Service Provider/Vendor

Alumni

**Construction/Maintenance Contractor – Requires the completion of the bottom

Applicant Signature (Sign in Ink) Date signed (mm/dd/yyyy) Home Telephone Number

COR Name/Sponsor Name and ext.

(Federal Employee)

Sponsor Signature: (Federal Employee)

**Construction/Maintenance Contractor:

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

Access is required to the following facility (ies) / locations where work areas are partitioned and/or fully separated from occupied areas, with isolated access for construction/maintenance contractors:

NCIC Check Date Initials Badge Issue Date

Document Number (DN)

52 (REV. 06-2020)

NIST PR 2401.01

THIS DOCUMENT CONTAINS PII: PLEASE USE SECURE METHODS WHEN SUBMITTING

*Hand-Carry (Gaithersburg)Bld.101 Rm.B08; (Boulder)Bld.51 Visitor Center *Internal mail service (Gaithersburg) MS 1373 *Fax (Gaithersburg) x3303 *Encrypted E-mail (Gaithersburg) badgeoffice@nist.gov. Please do not use N-files

NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

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

Sponsor's Division #

Badge #