SAMPLE_SECNAV_5512_1.pdf

i will be the base sponsor for the site visit provide photo copy of documents selected below in the email request.

DO NOT password protect the document as it is being reviewed by mulitple levels of security at SUBASE Kings Bay.

X

If dual citizenship make sure this is provided

0MB 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 1ZJ 0800-1100 □ OTHER December 3-5 WORK DAYS: □ SN □ M IZJT ow □ TH □ F □ST

PRIOR FELONY CONVICTIONS

29_ Have you ever been convicted of a Felony? □YES IZJNO

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 PENAL TY 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

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

36_ NCIC CHECK PERFORMED BY: 37. RESULTS OF NCIC CHECK: 38_ 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 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 make sure initials are here make sure initials are here barbara.czinder Highlight barbara.czinder Highlight barbara.czinder Highlight barbara.czinder Highlight