Attachment 5 - Site Visit Access Request Form.pdf

CUI (when filled in) 0MB 0703-0061 05/31/2024

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

PRIVACY ACT STATEMENT:

AUTHORITY: 1 O U.S.C. 113, Secretary of Defense; DoD Directive 1000.25, DoD Personnel Identity Protection (PIP) Program; DoD Instruction 5200.08, Security of DoD Installations a�d Resources and the DoD Physical Security Review Board (PSRB); DoD 5200.08-R, Physical Security Program; DoD Directive 5200.27, Acquisition of Information Concerning Persons a d Organizations not Affiliated with the Department of Defense (Exception to policy memos); Directive-Type Memorandum (DTM) 09-012, Interim Policy Guidance for DoD Physical Access Control; DTM 14-005, DoD Identity Management Capability Enterprise Services Application (IMESA) Access to FBI National Crime Information Center (NCIC) Files; and E.0. 9397 (SSN), as amended; OPNAVINST 5530.14E, Navy Physical Security and Law Enforcement Program; Marine Corps Order P5530.14, Marine Corps Physical Security Program Manual;

SORNNM05512-2 Badge and Access Control System Records and DMDC 16, Identity Management Engine for Security and Analysis (IMESA): http://dpcld.defense.gov/Privacy/ SORNslndex

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 processingflnformation services for designated populations for purposes of protecting U.S./Coalition/allied governmenUnational 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:

5. RACE

□AMERICAN INDIAN or ALASKA

(Check one or more): NATIVE □ASIAN

3. MIDDLE NAME:

□ BLACK or AFRICAN AMERICAN

6. GENDER

(Check one):

□MALE □FEMALE 17. DATE OF BIRTH: 1

8. CITY OF BIRTH:

4. NAME SUFFIX:

D Jr. D Sr. D I □ II 0111 0 IV

□ HISPANIC OR LATINO

NATIVE HAWAIIAN

□ OR OTHER PACIFIC

ISLANDER

�ITE

9. STATE OF BIRTH:

10. BIRTH COUNTRY:

11. US CITIZEN (Check): □ YES 112. DUAL CITIZENSHIP: □YES □No

□ 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.

13. IDENTITY SOURCE 14. DOCUMENT 15. ISSUED BY

DOCUMENTS PRESENTED: NUMBER: STATE/COURT:

D Social Security No.

D State ID/Drivers License

D Passport No.

D Certification Number and Petition Number

D Derived - Parent's Certification Number:

D Alien Registration No.

Date of Entry:

OTHER APPROVED IDENTITY SOURCE DOCUMENTS:

19. WEIGHT 20. HEIGHT 21. HAIR COLOR (Check one):

(Pounds): (Inches): □ Blond □ Brown □ Black □ Gray □

0 White □ Silver □ Auburn □ Bald

23. HOME ADDRESS (Include city, state, zip code):

24. BASE SPONSOR'S NAME:

SECNAV 5512/1 (MAY 2021) CUI (when filled in)

16. ISSUED BY 17. ISSUED: 18. EXPIRES:

COUNTRY:

United States

United States

United States

United States

I Port of Entry:

22. EYE COLOR (Check one):

Red □ Brown D Green □ Blue □ Hazel

□ Black D Gray □ Violet D Unknown HOME PHONE (Include Area Code):

SPONSOR PHONE (Include Area Code):

Controlled by: OoN CUI Category: PRVCY

LDC: FEDCON

POC: Rodney Ramseur, rodney.ramseur@navy.mil, 202-433-4281 http://dpcld.defense.gov/Privacy/ mailto:rodney.ramseur@navy.mil

CUI (when filled in) 0MB 0703-0061 05/31/2024

EMPLOYMENT ACTIVITY INFORMATON

25. EMPLOYER NAME AND ADDRESS (Include city/slate/zip code):

I EMPLOYER PHONE (Include Area Code):

26. SUPERVISOR NAME AND ADDRESS (Include city/state/zip code):

I SUPERVISOR PHONE(/nclude Area Code):

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

WORK HOURS: □ 0600-1800 □ 0800-1700 □ OTHER WORK DAYS: OsN □ M Dr Ow 0TH OF Osr

PRIOR FELONY CONVICTIONS

28. Have you ever been convicted of a Felony? □YES □NO

Initial

REQUIREMENT TO RETURN LOCAL POPULATION ID CARD

29. 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

30. 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 (OHS).

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.

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

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

35. NCIC CHECK PERFORMED BY: 36. RES UL TS OF NCIC CHECK: 37. RESULTS OF LOCAL RECORDS CHECK:

□NO RECORDS □RECORD IDENTIFIER □NO RECORDS □RECORD IDENTIFIER

RECORD NUMBER: 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 applicanUvisitor 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 (MAY 2021)

CUI (when filled In)

Cont/oiled by: OoN CUI Category: PRVCY

LDC: FEDCON

POC: Rodney Ramseur.rodney.ramseu1@navy.mil, 202-433--4281 mailto:rodney.famseur@navy.mil

CUI (when filled in)

Instruction for completing the Local Population Access Registration Form

OMB 0703-0061 05/31/2024

INSTRUCTIONS: Please complete all information in black ink (printed) or by typing. By voluntarily providing your Personal Information, you agree to the following terms and restrictions:

RESTRICTIONS: Local Population Identification Card/Base Access Pass may only be used by person to whom they are issued and for the specific business/purpose issued. Applicants are reminded that soliciting (i.e., door-to-door sales) is prohibited on the base, and that such activity is grounds for cancellation of the Pass.

Additionaliy, such action may result in debarment from the base and legal action. The Base Commanding Officer has discretion over specifying the period of validity for any Local Population ID Cards/Base Access Passes that are issued under his/her jurisdiction.

Review the Privacy At Statement that is printed at the top of the form

Block 1 Block 2 Block 3 Block 4 Block 5 Block 6 Block 7 Block 8 Block 9 Block 10:

Block 11 Block 12:

Block 13:

Block 14:

Block 15:

Block 16:

Enter the Last Name.

Enter the First Name.

Enter the Middle Name.

If applicable, check the box for Name Suffix.

Check the applicable box for Race.

Check the applicable box for Gender.

Enter Date of Birth.

Enter City of Birth.

Enter State of Birth.

Enter Country of Birth.

Check the applicable box for US Citizenship.

If not a US Citizen, enter the name of the Country of Citizenship.

Two forms of identity source documents from the list of acceptable documents listed below must be presented to the base registrar with this completed form. Check the box for the type of Documents that will be presented for identity proofing. If the document type is not listed, use the two rows under Other Approved Identity Source Documents to enter the type of document(s) that you will present.

Enter the Document Number located on the Identity Proofing Source document that was checked in Block 13.

Enter the State that issued the Identity Source Document.

Enter the Country that issued the Identity Source Document.

Block 17:

Block 18:

Block 19:

Block 20:

Block 21:

Block 22:

Block 23:

Block 24:

Block 25:

Block 26:

Block 27:

Block 28:

Block 29:

Block 30:

Enter the Date that the Identity Source Document was issued.

Enter the Date that the Identity Source Document will expire.

Enter Weight in pounds.

Enter Height in inches.

Check the applicable box for Hair Color.

Check the applicable box for Eye Color.

Enter Home Address Including City, State, Zip Code, and Home Telephone Number.

Enter Name of Registrant's Base Sponsor and Base Sponsor's Telephone Number.

Enter Employer Name and address including City, State, Zip Code, and Employer's Telephone Number.

Enter Supervisor's Name including City, State, Zip Code, and Supervisor's Telephone Number.

Check the applicable box for Work Hours box or check the OTHER box and enter the work hours, then check applicable boxes for Work Days.

Block 28: Check the applicable answer if you have been convicted of Felony and enter initials.

Check the applicable box for felony conviction.

Enter initials to accept terms for returning Local Population Identification Card.

Sign and date the form to attest that the foregoing information is true and complete to best of your knowledge.

LIST OF ACCEPTABLE DOCUMENTS - All documents must not be expired.

Must present one selection from List A or a combination of one selection from List B and one selection from List C.

List A - Documents that Establish Identity and List B - Documents that Establish Identity Employment Authorization OR AND

List C - Documents that Establish Employment Authorization

J__ 11 R Passport nr 11 St Passport Card

2. Permanent Resident Card or Alien Registration Receipt Card (Form 1-551).

3. Foreign passport that contains a temporary 1-551 stamp or temporary 1-551 printed notation on a machine-readable immigrant visa.

4. Employment Authorization Document that contains a photograph (Form 1-766).

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

a. Foreign Passport; and

b. Form 1-94 or Form I-94A that has the following:

(1) The same name as the passport; and

(2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with and restrictions or limitations identified on form.

6. Passport from the Federal States of Micronesia (FSM) or the Republic of the Marshal Islands (RM) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United Stated and FSM or RM.

J__Dri'/nr's license nr ID card issued hy a Statp nr outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address.

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address.

3. School ID card with a photograph

4. Voter's registration card.

5. U.S. Military card or draft record.

6. Military dependent's ID card.

7. U.S. Coast Guard Merchant Mariner Card.

8. Native American tribal document.

9. Driver's license issued by a Canadian government authority.

For persons under age 18 who are unable to present a document listed above:

10. School record or report card.

11. Clinic, doctor, or hospital record.

12 Day-care or nursery school record.

J__A Social Spnnrity Arrnnnt Numhpr card unless__ the card includes one of the following restrictions:

(1) NOT VALID FOR EMPLOYMEMT

(2) VALID FOR WORK ONY WITH INS

AUTHORIZATION.

(3) VALID FOR WORK ONLY WITH DHS

AUTHORIZATION.

2. Certification of Birth Abroad issued by the

Department of State (Form FS-545).

3. Certification of Birth issued by the Department of

State (Form DS-1360).

4. Original or certified copy of birth certificate issued by a State, county, municipal authority or territory of the United States bearing an official seal.

5. Native American tribal document.

6. U.S. Citizen ID Card (Form 1-197).

7. Identification Card for Use of Resident Citizen in the United States (Form 1-179).

8. Employment authorization document issued by the Department of Homeland Security.

The remainder of the form will be completed by the Base Registrar Person conducting Identify Proofing process and NCIC check.

AGENCY DISCLOSURE STATEMENT:

The public reporting burden for this collection of information, OMB 0703-0061, is estimated to average ten (10) minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, Executive Services, atwhs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN RESPONSE TO THE ABOVE ADDRESS.

Responses should be sent to the Base Registrar.

SECNAV 5512/1 (MAY 2021) v^unuuiieu uy. uuin _ o f O CUI (when filled in) CUI Category: PRVCY Page O OT O

LDC: FEDCON

ROC: Rodney Ramseur, rodney.ramseur@navy.mil, 202-433-4281 mailto:atwhs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil mailto:rodney.ramseur@navy.mil