NAWCWD_Badge_Form.pdf

Arrival Date Departure Date:

Grade:

State: Expiration:

Exp Dtd Year: Color: # of Doors:

DoD Dependent FN O/V

Community FN Guest

Contract #:

Other:

(X) No Escort

Required

(E) Escort Req'd

Sponsor's Initials

A Administration - Bldg. 00001

A China Lake Police - Bldg. 00879

A Foreign National Approval

C - CLPL

F - Flight Line

M - Michelson / Lauritsen Laboratories

N - North Restricted Areas

S - ECRD South Test Range

P - Photography Privileges

V - Vouching Privileges Sponsor's Name (Please Print and Sign): NAWS Badge # or Last (5) SSN: Date:

Security Approval Name/Signature: Date:

Privacy Act Statement AUTHORITY: 10 U.S.C.. 5013; 10 U.S.C.. 5041; OPNAVINST 5530.14D, Navy Physical Security; EQ 9397

ROUTINE USES: Information can be furnished to Federal, State, or local agencies, foreign governments, and designated contractors.

Policy #:

Applicants acknowledge they have read and will comply with the 'Statement of Agreement' on the back of the application. Name (Please Print and Sign):

Applicant's Signature:

FN Case#:

In-Vehicle (Approval Required)

PRINCIPAL PURPOSE: To maintain all aspects of proper access control; to issue badges, replace lost badges, and retrieve badges upon separation; to maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/exit times of personnel.

DISCLOSURE: Voluntary; however, refusal to furnish requested information can result in inability to verify essential personal information and/or disapproval of requested access application.

FN Day Pass (Identify area to be visited)

N3AT ISO

Phone #:

R - Remote North/SouthTest Range 5.2 Per Designation Memo

5.2 Per Designation Memo

N3AT ISO

N3AT, N46NS, 450000D,

N3/N32,410000D/E, VX-9, & VX-31

N3AT/NAVAIR

N3AT/NAVAIR

N3AT

N3AT, 741000D/E

N3AT,4.7 Per Memo

AREAS APPROVING CODE APPROVING OFFICIAL

NAME / TITLE / SIGNATURE

N00,00,7.0, 10.0, PAO,11.0

Other (Type):

Badge Type:

Area Access Badge One - Day Access

Temp Badge NCAC Application Pending (28 Days)

Authorized Controlled Area Access (Note: Sponsors are responsible for obtaining required area access approvals.

Model:Insurance Company

Vehicle Identification:

Registered Owner: License #: Decal # (If Issued):

Clearance Level:

Job TitleEmployer: Code:

SMO Verification (Name/Phone#): CAC / NCAC #:

SSN (Complete)

NAWSCL

BADGE REQUEST

INSTRUCTIONS: CHECK BLOCKS(S) FOR AREA(S) REQUIRED. Submit completed original to approving code. Sponsors are responsible for obtaining the appropriate approvals for restricted area(s) access.NAWS 5530/1 (Rev. 07-2013)

Name of Applicant (Last, First MI) Work / Contact Phone:

Citizenship (If not USA Provide Passport # / Permanent Residency #):Date of Birth:

1.

2.

3.

4.

5.

6. I certify that the personal data above is true and correct.

I agree to the following terms for the control and use of the Naval Air Weapons Station, China Lake (NAWSCL) badge issued to me:

Statement of Agreement

I am responsible for the security of the badge and will not leave it unsecured at any time. I will use the badge only for the purpose issued and I will not loan the badge to any other person or use it to bring unauthorized persons onto NAWS. I have read and I understand the Security Warning and the Privacy Act Statement on this form.

I will immediately report the loss or theft of the badge to NAWS Physical Security 939-1655 or after normal business hours to China Lake Police 939-3323. When no longer needed, I will return the badge to the Visitor's Center, at Bldg. 01487. I will surrender the badge to authorized security personnel upon request.

I understand and will ensure any vehicle I drive aboard NAWS is insured and registered with the appropriate state law. A copy of current registration and proof of insurance will be maintain with the vehicle at all times. I further understand entrance into NAWS constitutes a consent to search.

I understand solicitation is not authorized.

Community/Temporary badges are normally authorized from 0600 to 2200 hours for access to Main Site, but may change at any time.

Badge Request Jul 2013