NSAB_5512-1.pdf

Memorandum to Request Transaction(s) From Naval Support Activity Bethesda Pass and Identification Office

From: ________________________________________ _______________ Name of Member’s Department Head, Service Chief, or Above Rank

To: Security Director, Naval Support Activity Bethesda (Pass & ID Office) Subj: REQUEST FOR EMPLOYEE TO RECEIVE SERVICES FROM PASS & ID

1. Respectfully request the employee identified in Section I, receive the identification credentials indicated in Section II.

SECTION I – To be completed by MEMBER:

Last Name of Member First Name Middle Initial

Rank Rate / Specialty Branch of Service Officer Corps

Command Department Title

PRD (Military Projected Rotation Date) CAC / Military ID Expiration Date If Temporarily Assigned, Date Assignment Ends

Status (Please Check)

Active Duty Reserve Civil Service Permanent Civil Service Temporary Military Retiree

Contractor Permanent (EMPLOYED ONBOARD NSAB FULL TIME - NOT A VISITING CONTRACTOR OR VENDOR)

Other (Please specify): _________________________________________________

PRIVACY ACT STATEMENT

Title 5 of the U.S. Code authorizes collection of this information. The primary use of this information is by management and by the Naval Support

Activity Bethesda Pass and ID Office. This information may be used to approve access to the installation and additional disclosures of this information may be used for statistical purposes and in the course of a law enforcement procedure or lawful investigation.

By signing below, I certify that I have read the Privacy Act Statement and that the information above is correct to the best of my knowledge.

Signature of Member Date Entered into Pass & ID System by Entered into CLEOC by

SECTION II – To be completed by DEPARTMENT HEAD, SERVICE CHIEF, OR ABOVE:

Items Required by Employee (Please Check)

WRNMMC Staff ID Badge (ONLY for WRNMMC personnel and those whose duties cause them to frequent WRNMMC buildings for OFFICIAL business.)

NSAB Access Credential (ONLY for individual personnel without a CAC whose duties require frequent installation access but do not require a CAC.) Form

SECNAV 5512/1 must be submitted in conjunction with request.

Temporary Installation Pass (ONLY for personnel who are checking-in who will be issued a CAC, but do not yet have their CAC.)

** All Parking Permit Requests Must go Through and be Transmitted to Pass and ID by the Cognizant Parking Champion **

By signing below, I certify that the information on this memorandum is correct to the best of my knowledge, and that the employee identified on this memorandum is authorized and required to receive the ID credentials indicated herein. I also certify that I am not requesting an NSAB Access Credential for a vendor, visiting contractor, or person who should be enrolled in the Navy Commercial Access

Control System (NCACS/RAPIDGate) Program.

Signature of Dept. Head, Service Chief, or Above Date Government Email Phone Number

NSAB 5512/1 (9/14)