Color_Coded_Pass_Aplication _6-24-2011.pdf

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.

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APPLICANT / EMPLOYEE

derek.sorensen1 Text Box

NAVFAC SE / COR

derek.sorensen1 Text Box

PRIME CONTRACTOR

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