Atch_3_45_SFS_Badge-Visitor_Request_Form.pdf

45 SFS BADGE/VISITOR REQUEST

(SUBJECT TO THE PRIVACY ACT OF 1974)

REQUIRES ACCESS TO:

LONG TERM SHORT TERM

PAFB CCAFS

Contractor

Student

Resident

Visitor

Caretaker

Golf

PRIVACY ACT STATEMENT

AUTHORITY: E.O. 9397; The Privacy Act of 1974, 5 U.S.C. 522a; DODD 8500.1 PRINCIPAL PURPOSE(S): To provide necessary information to 45th Space Wing (45 SW) to determine if applicant meets access control requirements IAW HSPD12, DoD 5200.8, DTM 09-12 and FIPS201. Use of SSN is necessary to make positive identification of an applicant. Records in the Defense Biometric Identification System (DBIDS) are maintained to support DoD physical security and information assurance programs and are used for identity verification purposes, to record personal property registered with the DoD and for producing facility management reports. SSN, Drivers License Number or other acceptable identification will be used to distinguish individuals who request entry to 45 SW property.

DISCLOSURE: Voluntary. However, failure to provide the requested information may result in denial of a badge or visitor pass and denial of entry to 45 SW property.

I. IDENTIFICATION

NAME(First, Middle Initial, Last) BIRTH(MM/DD/YYYY) SOCIAL SECURITY NO

DRIVER’S LICENSE NO STATE COMPANY/UNIT

US CITIZEN? ALIEN/PASSPORT/BIRTH COUNTRY(Non-US Citizen) GENDER

HEIGHT(ft/In)

WEIGH(lbs)

EYE COLOR HAIR COLOR

YES

NO

II. ATTESTATION

All badges are government property and should be returned to the Visitor Control Center or Security Manager upon completion of official business.

Immediately report lost or stolen badges to your Security Manger.

SIGNATURE DATE

III. ORGANIZATION/SPONSOR AND ACCESS DATES/TIMES

START DATE(MM/DD/YYYY)

DAYS REQUESTING ACCESS

Hours (e.g.

0730- 1630)

MON TUE WED THU FRI SAT SUN

END DATE(MM/DD/YYYY)

REQUESTOR AGENCY/ORGANIZATION

DUTY PHONE

SIGNATURE AND DATE

REMARKS

DOES APPLICANT HAVE A CURRENT SECURITY CLEARANCE OR FAVORABLE BACKGROUND CHECK? YES NO

DOES APPLICANT HAVE A NON-DOD ISSUED COMMON ACCESS CARD OR TWIC? YES NO

VERIFIED BY(Print Name) SIGNATURE

DATE

IV. ACKNOWLEDGEMENT OF POTENTIAL TOXIC HAZARDS (CCAFS ONLY)

Visitors must be aware that highly toxic chemicals (Nitrogen Tetroxide, Aerozine-50, Anhydrous Hydrazine and Monomethyl Hydrazine) used during launch vehicle processing pose potential risks of airborne toxic hazards at CCAFS. In the event of a toxic chemical release, all personnel including visitors must comply with posted warning signs and announcements on the Cape Aural Warning Zones system. This includes stopping your vehicle and waiting for security personnel to arrive when traffic lights on posted toxic hazard signs are activated red. Emergency procedures will evacuate personnel to designated assembly points that are upwind of a toxic chemical release point. CCAFS facilities that process these toxic chemicals include: all launch complexes; Fuel Storage Area 1 (FSA1);

Satellite Processing & Integration Facility (SPIF); Defense Satellite Communication System Processing Facility (DPF); and the Solid Motor Assembly Building (SMAB). Dial 911 (853-0911 cell phone) to report any emergency.

I ACKNOWLEDGE RECEIPT AND UNDERSTANDING OF THIS SAFETY WARNING BY INITIALING HERE

V. 45 SFS USE ONLY

DATE OF NCIC CHECK NCIC OPERATOR COMMENTS

INSTRUCTIONS FOR COMPLETING FORM (Must be typed or printed clearly in ink).

Use this form to request a Defense Biometric Identification System (DBIDS) badge or visitor pass for personnel requiring access to Patrick AFB and/or Cape Canaveral Air Force Station.

Badge Type:

Select either Patrick AFB and/or Cape Canaveral Air Force Station for installation access. Check long term (access for 60 days or longer) or short term paper pass (access less than 60 days). Check the type of badge (e.g. contractor, student, visitor, Golf).

I. Identification Section

Name – Enter individuals Last Name, First Name and Middle Initial.

Suffix – Enter the individuals Suffix, if applicable, e.g. Jr, II, Sr, III

Drivers License/State – Enter individuals complete driver’s license number and state issued.

Social Security Number – Enter the individual’s social security number.

Birth – Date of Birth using MM/DD/YYYY format.

US Citizen – Check either Yes or No is the individual is a US citizen

Alien Passport – Used to document Alien, Passport or immigration number of non-US citizens

Gender – Enter either M or F

Height – Enter height of individual in feet and inches, e.g. 5’8”

Weight – Enter weight in pounds, e.g. 175

Eye Color – Enter individual’s eye color, e.g. Black, Blue, Gray, Green, Hazel, Violet

Hair Color – Individual’s hair color, e.g. Auburn, Black, Blond, Gray, Red, Silver, White

II. Attestation

Completed by applicant at time of badge/visitor pass issue at Visitor Control Center

III. Sponsoring Organization and Access Date/Times

Start Date - Enter date the badge/visitor pass is to become effect.

End Date – The date which the badge/visitor pass expires.

Days Requesting Access – Enter time(s) for authorized installation access for each day of the week. Leave blank for default DBIDS access 24x7.

Requestor – Enter name of person completing access request form.

Agency/Organization – Enter requestor’s organization

Duty Phone – Enter requestor’s duty phone.

Signature/Date – Requestor’s signature and date.

Remarks – Enter any additional processing instructions.

Current Security Clearance or Favorable Background Check – If known, select yes or no if applicant has a favorably adjudicated background investigation.

Non-DoD Issued Common Access Card or Transportation Worker Identification Credential (TWIC) – Select yes or no if subject has a non-DoD CAC or TWIC.

Investigation Date – Date a background investigation was completed as documented in the Joint Personnel Adjudication System (JPAS).

Verified By – Name of individual verifying security clearance/background investigation.

Security Manager Signature – Self-explanatory.

Date – Self-explanatory.

IV. Acknowledgement of Potential Toxic Hazards (CCAFS Only)

Initialed by applicant at the Visitor Control Center if access to CCAFS is being requested.

V. 45 SFS use only

Internal use only.

Directions for Submitting:

Page one of the form may be delivered to either the Patrick AFB Visitor Control Center at (321) 494-6558 or the CCAFS Visitor Center at (321) 853-3441. Allow three duty days for processing,