J-0200000-04 Form Tass Registration Form.pdf

TASS REGISTRATION REQUEST (TRR)

This form is being submitted for (select only one) ----------> Initial Issuance: Reissuance:6 Month Reverification:

Last Name: Middle Name:First Name:

Section I: Applicant Data

Cadency Name:

SSN or FIN: Date of Birth:

(mm/dd/yyyy)

E-mail Address:

Personnel Category ------->

Card Expiration Date:

(mm/dd/yyyy)

(Include option years. Date not to exceed 3 years or the Contract End Date)

Contract End Date:

(mm/dd/yyyy)

Contract Number:

AUTHORITY: 10 U.S.C. 133 and E.O. 9397 Privacy Act Statement PRINCIPAL PURPOSE(S): Collection of social security numbers and other personal identifiers is used to ensure positive identification of individuals in order to successfully register them as TASS applicants.

ROUTINE USERS: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use as follows: The "Blanket Routine Uses" set forth at the beginning of OSD's compilation of systems of records notices apply to this system. The Federal, State agencies and private entities, as necessary, on matters relating to securing information during the conduct of official business, utilization review, professional quality assurance, program integrity, civil and criminal litigation, and access to Federal government facilities, computer systems networks, and controlled areas.

DISCLOSURE: Voluntary, however, failure to provide this information will result in failure to register an individual as a TASS applicant.

Section II: Eligibility Requirements (Select Only One Option)

The Applicant requires access to both a DoD facility and logon access to a DoD network. Network Name =

The Applicant will be required to travel to a foreign country as a 'regular' requirement of their job. Name of Foreign Country =

The Applicant requires access to 2 or more DoD facilities, on behalf of the DoD, on a recurring basis for a period of 6 months or more.

*(NOT applicable to Contractors assigned to CONUS, Hawaii and Joint Region Marianas facilities that use NCACS for base access control).

The Applicant requires remote access to a DoD network that use only the CAC logon for user authentication. Network Name = *(NOT applicable to Contractors assigned to CONUS, Hawaii and Joint Region Marianas facilities that use NCACS for base access control).

The Applicant is a Volunteer who requires frequent access to a DoD network (Applicable to Volunteers only). Network Name =

Section III: Background Vetting (Select Only One Option)

CAC Issuance - Contractors & other eligible Personnel

VOLAC Issuance - Volunteer Personnel

Section IV: Sponsor Responsibilities This is the Government Employee authorizing the issuance of a credential

Sponsor's Phone #: Sponsor's Email:

(Select/Input category )

Date: (mm/dd/yyyy)

Phone #: Email Address Date: (mm/dd/yyyy)

A NAC, or higher investigation, has been submitted to OPM 'and' an FBI fingerprint check has returned with favorable results.

The Applicant possesses a valid National Agency Check (NAC) or higher background investigation.

A NACI, or DoD-determined NACI equivalent, investigation has been submitted to OPM 'and' an FBI fingerprint check has returned with favorable results

The Applicant possesses a DoD-determined NACI equivalent investigation: { Select/Input NACI equivalent investigation here } ---->

The Applicant possesses a valid National Agency Check with Inquiries (NACI).

Validating authority information for the above background vetting information must be provided or TA will not process this request.

I AGREE, if there is a change in the Applicant's eligibility to retain the credential I am authorizing, I will notify the TA of the change in status so he/she may terminate the record in TASS or arrange a transfer of the TASS record to another TA. If the Applicant is no longer eligible to retain the credential I will confiscate it and turn it in at a RAPIDS ID card office for disposition.

Sponsor's information must be provided or TA will not process this request.

Digital Signature of Individual validating background vetting

Digital Signature of Government Sponsor

TASS REGISTRATION REQUEST (TRR)

This form is being submitted for (select only one) ----------> Section I: Applicant Data (mm/dd/yyyy)

Personnel Category -------> (mm/dd/yyyy)

(Include option years. Date not to exceed 3 years or the Contract End Date) (mm/dd/yyyy) AUTHORITY: 10 U.S.C. 133 and E.O. 9397 Privacy Act Statement PRINCIPAL PURPOSE(S): Collection of social security numbers and other personal identifiers is used to ensure positive identification of individuals in order to successfully register them as TASS applicants.

ROUTINE USERS: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use as follows: The "Blanket Routine Uses" set forth at the beginning of OSD's compilation of systems of records notices apply to this system. The Federal, State agencies and private entities, as necessary, on matters relating to securing information during the conduct of official business, utilization review, professional quality assurance, program integrity, civil and criminal litigation, and access to Federal government facilities, computer systems networks, and controlled areas.

DISCLOSURE: Voluntary, however, failure to provide this information will result in failure to register an individual as a TASS applicant.

Section II: Eligibility Requirements (Select Only One Option) Section III: Background Vetting (Select Only One Option) CAC Issuance - Contractors & other eligible Personnel VOLAC Issuance - Volunteer Personnel Section IV: Sponsor Responsibilities This is the Government Employee authorizing the issuance of a credential (Select/Input category ) (mm/dd/yyyy) (mm/dd/yyyy) Validating authority information for the above background vetting information must be provided or TA will not process this request.

I AGREE, if there is a change in the Applicant's eligibility to retain the credential I am authorizing, I will notify the TA of the change in status so he/she may terminate the record in TASS or arrange a transfer of the TASS record to another TA. If the Applicant is no longer eligible to retain the credential I will confiscate it and turn it in at a RAPIDS ID card office for disposition.

Sponsor's information must be provided or TA will not process this request.

Digital Signature of Individual validating background vetting Digital Signature of Government Sponsor 8.2.1.3144.1.471865.466429