SAMPLE FOR US CITIZEN-SECNAV5512-1.pdf

OMB 0703-0061 Exp. 31 Mar 2017

DEPARTMENT OF THE NAVY LOCAL POPULATION ID CARD/BASE ACCESS PASS REGISTRATION

PRIVACY ACT STATEMENT:

AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; OPNAVINST 5530.14E, Navy Physical Security; Marine Corps Order 5530.14A, Marine Corps Physical Security Program Manual; and E.O. 9397 (SSN), as amended, SORN NM05512-2 .

PURPOSE(S): To control physical access to Department of Defense (DoD), Department of the Navy (DON) or U.S. Marine Corps Installations/Units controlled information, installations, facilities, or areas over which DoD, DON, or U.S. Marine Corps has security responsibilities by identifying or verifying an individual through the use of biometric databases and associated data processing/information services for designated populations for purposes of protecting U.S./Coalition/allied government/national security areas of responsibility and information; to issue badges, replace lost badges, and retrieve passes upon separation; to maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/exit times of personnel.

ROUTINE USE(S): To designated contractors, Federal agencies, and foreign governments for the purpose of granting Navy officials access to their facility.

DISCLOSURE: Providing registration information is voluntary. Failure to provide requested information may result in denial of access to benefits, privileges, and DoD installations, facilities and buildings.

IDENTITY PROOFING AND APPLICANT INFORMATION

1. LAST NAME: 2. FIRST NAME: 3. MIDDLE NAME: 4. NAME SUFFIX:

Jr. Sr. I II III IV

5. HISPANIC OR 6. RACE NATIVE HAWAIIAN

AFRICAN AMERICAN AMERICAN INDIAN OR

YES NO WHITE ASIAN OR OTHER PACIFIC

LATINO (Check one): (Check one or more): OR BLACK ALASKIN NATIVE

ISLANDER

7. GENDER 8. DATE OF BIRTH: 9. CITY OF BIRTH: 10. STATE OF BIRTH: 11. BIRTH COUNTRY:

MALE FEMALE

(Check one):

13. DUAL CITIZENSHIP: YES NO

12. US CITIZEN (Check): YES NO

CITIZENSHIP IF OTHER THAN US (Country) :

U.S. Citizen Minimum Documentation Required:

By Birth - Social Security No and/or State ID/Drivers License.

Naturalized - Certification Number, Petition Number, Date, Place and Court, United States passport number, Social Security No and/or

State ID/Drivers License.

Derived - Parent's certification number, Social Security No and/or State ID/Drivers License.

Alien Minimum Documentation Required:

Registration Number, Expiration date, Date of entry, Port of entry.

14. IDENTITY SOURCE 16. ISSUED BY 17. ISSUED BY

15. DOCUMENT NUMBER: 18. ISSUED: 19. EXPIRES:

DOCUMENTS PRESENTED: STATE/COURT: COUNTRY:

Social Security No. United States

State ID/Drivers License United States

Passport No.

Certification Number and

Petition Number

Derived - Parent's United States

Certification Number:

Alien Registration No. United States

Date of Entry: Port of Entry:

OTHER APPROVED IDENTITY SOURCE DOCUMENTS:

20. WEIGHT 21. HEIGHT 22. HAIR COLOR (Check one): 23. EYE COLOR (Check one):

(Pounds): (Inches): Blond Brown Black Gray Red Brown Green Blue Hazel

White Silver Auburn Bald Black Gray Violet Unknown

24. HOME ADDRESS (Include city, state, zip code): HOME PHONE (Include Area Code):

25. BASE SPONSOR'S NAME: SPONSOR PHONE (Include Area Code):

EMPLOYMENT ACTIVITY INFORMATON

26. EMPLOYER NAME AND ADDRESS (Include city/state/zip code): EMPLOYER PHONE (Include Area Code):

27. SUPERVISOR NAME AND ADDRESS (Include city/state/zip code): SUPERVISOR PHONE (Include Area Code):

SECNAV 5512/1 (APR 2014) FOR OFFICIAL USE ONLY WHEN FILLED - PRIVACY SENSITIVE: Page 1 of 3 Any misuse or unauthorized disclosure of this information may result in both criminal and civil penalties.

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OMB 0703-0061 Exp. 31 Mar 2017

28. Check the applicable box for WORK HOURS box or check the OTHER box and enter the work hours, then check the applicable for WORK DAYS:

WORK HOURS: 0600-1800 0800-1700 OTHER WORK DAYS: SN M T W TH F ST

PRIOR FELONY CONVICTIONS

29. Have you ever been convicted of a Felony? _______YES NO Initial

REQUIREMENT TO RETURN LOCAL POPULATION ID CARD

30. I understand that I am required to return my Local Population Identification Card to the Base Pass Office when it expires or if my employment is terminated for any reason. ________ (initial)

AUTHORIZATION AND RELEASE AND CERTIFICATION

31. I hereby authorize the DOD/DON and other authorized Federal agencies to obtain any information required from the Federal government and/or state agencies, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense Security Service (DSS), the U.S. Department of

Homeland Security (DHS).

I have been notified of DON right to perform minimal vetting and fitness determination as a condition of access to DON installation/facilities. I understand that I may request a record identifier; the source of the record and that I may obtain records from the State Law Enforcement Office as may be available to me under the law. I also understand that this information will be treated as privileged and confidential information.

I release any individual, including records custodians, any component of the U.S. Government or the individual State Criminal History Repository supplying information, from all liability for damages that may result on account of compliance, or any attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD RESULT IN FINES AND/OR IMPRISONMENT UP TO FIVE YEARS.

BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE YOU HAVE ANSWERED ALL QUESTIONS FULLY AND CORRECTLY.

I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE BY ME ON THIS FORM ARE TRUE, COMPLETE AND CORRECT

DATE _______________ SIGNATURE ________________________________________

FINAL DETERMINATION ON YOUR ACCESS: The Base Commanding Officer has final authority for determination on granting physical access to

DON controlled installations/facilities under his/her jurisdiction.

36. NCIC CHECK PERFORMED BY: 37. RESULTS OF NCIC CHECK:

NO RECORDS RECORD IDENTIFIER

RECORD NUMBER:

32. INFORMATION VERIFIED BY: 33. ENTERED IN C/S SYSTEM BY: 34. PASS ISSUE DATE: 35. PASS EXPIRATION DATE:

BELOW COMPLETED BY BASE REGISTRAR PERSON CONDUCTING IDENTY PROOFING and NCIC CHECK

38. RESULTS OF LOCAL RECORDS CHECK:

NO RECORDS RECORD IDENTIFIER

RECORD NUMBER:

Office of Under Secretary of Defense Directive-Type Memorandum (DTM) 09-012, "Interim Policy Guidance for DoD Physical Access Control,"

December 8, 2009. DTM 09-012 requires that DoD installation government representatives query the National Crime Information Center (NCIC) and

Terrorist Screening Database to vet the claimed identity and to determine the fitness of non-federal government and non-DoD-issued card holders (i.e.

visitors) who are requesting unescorted access to a DoD installation. The minimum criteria to determine the fitness of a visitor is: 1) not on a terrorist watch list; 2) not on an DoD installation debarment list; and 3) not on a FBI National Criminal Information Center (NCIC) felony wants and warrants list.

Additionally, SECNAV Memo, Policy for Sex Offender Tracking and Assignment and Access Restrictions within the Department of the Navy, of 7 Oct 08 and OPNAVINST 1752.3 established the Navy's policy on sex offenders, requiring Region Commanders (REGCOMs) and Installation Commanding

Officers (COs) to prohibit sex offender access to DoN facilities and Navy owned, leased or PPV housing. This form describes the authority and purpose to collect and share the required information; and identifies the applicant/visitor and sponsor; and authorizes the DoD to perform the minimum vetting and fitness determination criteria. A favorable response on the vetting and fitness determination is required to receive access to DOD-controlled installation/facilities.

SECNAV 5512/1 (APR 2014) FOR OFFICIAL USE ONLY WHEN FILLED - PRIVACY SENSITIVE: Page 2 of 3 Any misuse or unauthorized disclosure of this information may result in both criminal and civil penalties.

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