Attachment 22- Badge Request 45 SFS Form V11.pdf

45 SFS CREDENTIAL REQUEST FORM

(SUBJECT TO THE PRIVACY ACT OF 1974)

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 determine if applicant meets installation access control requirements IAW HSPD12, DoD 5200.8, DTM 09-12, FIPS201 and AFI 31-113. 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, Driver’s License Number or other acceptable identification will be used to distinguish individuals who request access to 45 SW property.

DISCLOSURE: Voluntary. However, failure to provide the requested information may result in denial of an access credential and denial of access to 45 SW property

REQUIRES ACCESS TO:

Patrick AFB Cape Canaveral AFS VAFB

LONG TERM

(60 days or more)

SHORT TERM

(59 days or less)

TYPE Govt Employee

Govt Contractor

Visitor

Volunteer

Student

Caretaker

Housing

I. VISITOR’S INFORMATION

NAME(First, Middle Initial, Last)

BIRTH(MM/DD/YYYY)

SOCIAL SECURITY NUMBER

DRIVER’S LICENSE NUMBER

STATE

COMPANY/UNIT

US CITIZEN? ALIEN/PASSPORT NUMBER/COUNTRY OF

BIRTH(non-US Citizens)

GENDER

HEIGHT(ft/In)

WEIGHT(lbs)

EYE COLOR

HAIR COLOR

YES

NO

Does Applicant have a valid Federally Issued Common Access Card (CaC)? YES NO

II. 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/SPONSOR

AGENCY/ORGANIZATION

DUTY PHONE

BADGING OFFICIAL/SPONSOR SIGNATURE

DATE

REMARKS

III. ADVISEMENT 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. Dial 911 (853-0911 cell phone) to report any emergency.

IV. ACKNOWLEDGEMENT OF INSTALLATION DRIVING PROCEDURES: INITIALS

V. 45 SFS USE ONLY

ON SRBW DATE OF NCIC CHECK NCIC OPERATOR COMMENTS

YES

NO

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

Directions for Submitting: Page one (1) of this form may be: 1) hand delivered by the badging official, 2) faxed to either the Patrick AFB Visitor Control Center (321) 494-6558 or the CCAFS Visitor Center at (321) 853-3441 or 3) emailed to 45SFS.S5V.CCAFSVCC@us.af.mil. Allow three (3) duty days for processing.

Credential Type: Select either Patrick AFB and/or Cape Canaveral Air Force Station for installation access. VAFB may be selected for those organizations with workcenters at both Cape Canaveral AFS and Vandenberg AFB. Check long term (60 days or more) or short term paper pass (59 days or fewer). Check reason (e.g. Employee, Contractor, Visitor, Volunteer, Housing).

I. Visitor’s Information:

Name – Enter individual’s legal first name, middle initial and last name. (Mandatory)

Birth – Date of Birth using MM/DD/YYYY format. (Mandatory)

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

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

Company/Unit - Name

US Citizen – Check either Yes or No if the individual is a US citizen. (Mandatory)

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

Federal issued Common Access Card (CAC) -- Select Yes or No

II. Sponsoring Organization and Access Date/Times (Completed by Sponsor):

Start Date - Enter date the card/visitor pass is to become effect. (Mandatory)

End Date – The date which the card/visitor pass expires. (Mandatory)

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

Requestor /Sponsor– Enter name of person completing access request form. (Mandatory)

Agency/Organization – Enter requestor’s organization (Mandatory)

Duty Phone – Enter requestor’s duty phone.

Signature/Date – Requestor’s signature and date. (Mandatory)

Remarks – Enter any additional processing instructions

III. Advisement of Potential Toxic Hazards (CCAFS Only): Reviewed/initialed by visitor.

IV. Acknowledgement of Installation Driving Procedure’s (IAW AFIs 31-218, Motor Vehicle Traffic Supervision and 91-207, The US Air Force Traffic Safety Program):

Personnel will comply with all rules and regulations while operating a vehicle within the jurisdiction of Patrick AFB/Cape Canaveral AFS. Failure to comply with established procedures may result in revocation of driving privileges.

- Personnel and their property are subject to search at any time

- Seatbelts must be worn at all times

- Texting while operating a motor vehicle is prohibited

- Talking on a cellular phone while operating a motor vehicle is prohibited unless using hands free technology.

V. 45 SFS use only: Internal use only.