N6883620Q0011_APPLICATION_FOR_ACTIVITY_ACCESS.PDF

Yes No Years

Other

Start Date End Date

Date:

Yes No

Activity Pass Information

CNRSE 5200.1 Form 1

Gender

Activity Photo Pass CAC Identification (White) CAC Identification (Green)

Activity Pass Number Issue Date Expiration Date Other

PASS/ID Official Name Idetnification Verified Identification # Photo Copy Retained

CAC Identification (Red) Activity Paper Pass

Pass Request

Signature:

1 Week 6-12 Mos

1 Month

Destination / Area of worksite on activity:

PHONE/AREA CODE

Point of Contact (POC) Name: POC's Command: POC's Phone #:

3-6 Mos.

How long will you need access? 1 Day (Check on of the following.)

Company/Contractor Name: Company/Contractor Phone #:

Contractor(Check one of the following.)

Vendor Delivery

An Alien with Employment Authorization Document (EAD)

Employment Authorization Document Number ________________

Insurance Company Name

State of Issuance

Reason for Access

Veh. Make

Insurance Policy #

***All Non-Citizen's must provide an Alien Registration Number or Employment Authorization Document (EAD) Number and original cards with application. Access to the activity will not be authorized without this information.

Driver License State of Issue

Have you ever been convicted of a felony?

If Yes. How many years since conviction?

I understand that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

DATE OF BIRTH PLACE OF BIRTH (State)PLACE OF BIRTH (City)

Social Security Number Driver Lincense Number

APPLICATION FOR ACTIVITY ACCESS

NAME (Last) First

Consent to Criminal History

Middle

I hereby acknowledge understanding, that with the voluntary completion of this application, I am requesting access to a Department of Defense (DOD) facility. I hereby authorize Navy Security Force personnel to receive any citizenship and criminal history record information pertaining to me, which may be in the files of any federal, state, or local law enforcement agencies.

PRINT CLEARLY FOR TIMELY PROCESSING

AUTHORITY: Privacy Act of 1974 (5 USC SECTION 552(A)(7)) 41 USC Section 423, 5CFR Section 2635.602, AR 340-21 Title 10 and 37 USC.

PRINCIPAL PURPOSE(S): To enable military security and/or law enforcement personnel to conduct Citizenship and Criminal Background investigations for civilians requesting access to DOD Facilities.

ROUTINE USE(S): To authorize access to DOD Facilities. Information may be reported to federal, state, and local law enforcement agencies with jurisdictional interest.

DISCLOSURE: Voluntary. Failure to provide requested information will result in denial of access to DOD Facilities.

Privacy Act Statement

I attest, under penalty of perjury, that I am (check one of the following): ***

Veh. Model Veh. Color License Plate #

A Lawful Permanent Resident. Alien Registration Number- A

A citizen of the United States.

Vehicle Information

Application Processing (For Navy Security Force Personnel Only)

Reason for Access?

Insurance Expiration Date

I agree to return the badge to the Security Officer upon termination of employment, completion of business transactions or any other reason that may cancel or alter my privilege for entry to the Station. I hereby agree to and certify that the above information and statements are true. I further agree to abide by all rules and regulations of this activity and subject myself and/or vehicle to search or detention for protection of information or property of the U.S. Government.

COUNTRY OF CITIZENSHIPCOLOR HAIR: COLOR EYES: HEIGHT: WEIGHT:

COUNTRY OF BIRTH

ADDRESS (Home)

SUPERVISOR'S SIGNATURE DATE:

DATE:

PHONE:

Requested Expiration Date:

COMPANY/ORAGNIZATION: PHONE AREA/CODE:

SIGNATURE OF APPLICANT _________________________________________________

EMPLOYER ADDRESS:

PHONE/AREA CODE:

SUPERVISOR'S PRINT

GOV POC SIGNATURE

NOT VALID WITHOUT SECURITY SEAL AND MARK

Date of Issue:

EXPIRATION DATE:START DATE:

Pass Issued By:

SECURITY PASS / ID OFFICIAL USE ONLY

RANK AND/OR TITLE

REQUEST FOR EMPLOYEE ACCESS

BADGE REQUESTED FOR ____ MONTHS (1YR MAX FOR CONTRACTORS)

DATE OF REQUEST:

ADDRESS (HOME): PHONE/AREA CODE: DATE OF BIRTH:

NAME (LAST) (FIRST) (MIDDLE)

CNRSE 5200.1 Form 2

CIVIL SERVICE

I agree to report immediately to the Security Pass/ID Section and my immediate supervisor in the event the badge is destroyed, lost or stolen. My supervisor will sign an acknowledgement of loss report before a new badge will be issued. FOR CONTRACTOR OR NON-APPROPRIATED FUND CONTRACTOR BADGE APPLICATIONS: I HEREBY CERTIFY THAT THE PERSON APPLYING ON THIS FORM IS EITHER A BORN OR NATURALIZED U.S. CITIZEN, PERMANENT RESIDENT ALIEN OR OTHERWISE LEGALLY ALLOWED EMPLOYMENT IN THE U.S.

(INITIAL):_____________

SOCIAL SECURITY NUMBER: KIND OF BADGE DESIRED (CHECK ONE)

COLOR BADGE:

OCCUPANTION OF APPLICANT:

I agree to return the badge to the Security Officer upon termination of employment, completion of business transactions or any other reason that may cancel or alter my privilege for entry to the Station. I hereby agree to and certify that the above information and statements are true. I further agree to abide by all rules and regulations of this activity and subject myself and/or vehicle to search or detention for protection of information or property of the U.S. Government. Please Initial: I am ________ am not _________ a U.S. Citizen.

Requested Start Date:

COLOR HAIR: COLOR EYES:

OTHER THAN ABOVE (Explain)

NON-APPROPRIATED

FUNDS

CONTRACTOR

HEIGHT: WEIGHT:

NOTICE: TITLE 18 USCA Sec. 132. (June 15, 1917,c.,30, Title X,Sec.3, 40 Stat. 228) FALSELY MAKING OR FORGING NAVAL, MILITARY, OR OFFICIAL PASS. Whoever shall falsely make, forge, counterfeit, alter, or tamper with any Naval, Military, or Official pass, or permit, issued by or under the authority of the United States, or with worngful or fraudulent intent shall use, or have in his possession any such pass or permit, or shall personate or falsely represent himself to be or not to be a person to who such pass or permit has been duly issued, or shall willfully allow any other person to have or use pass or permit, issued for his use alone, shall be fined not more than $2,000 or imprisioned not more than fine years, or both.

EMPLOYER:

APPLICANT WILL NOT WRITE BELOW THIS LINE

GOV'T HOST/CONTRACTING OFFICER ENDORSEMENT

From:_________________________________________________ of _______________________________________ (Activity ______________ GOVERNMENT LIAISON / POC) (ORGANIZATION) To: (Activity ) Pass/ID Office Supervisor

1. Security Pass/ID Section will issue an Antiterrorism/Force Protection pamphlet upon issuance of the badge.

2. In accordance with this application, it is requested that a badge be issued for the purpose and duration indicated.