N6945022R0002_JL6_CNRSE 5200-1.pdf

REQUEST FOR EMPLOYEE ACCESS

NAME (Last): NAME (First): NAME (Middle): DATE OF REQUEST:

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

SOCIAL SECURITY NUMBER: KIND OF BADGE DESIRED (Filled Out By Government Host)

COLOR OF HAIR: COLOR EYES: BADGE COLOR:

CIVIL SERVICE

HEIGHT: WEIGHT:

CONTRACTOR NON-APPROPRIATED FUNDS

EMPLOYER: OTHER THAN ABOVE (Explain)

EMPLOYER ADDRESS:

BADGE REQUEST FOR: MONTHS (1YR Max For Contractors)

PHONE/AREA CODE: APPLICANT OCCUPATION: START DATE: EXPIRATION DATE:

I agree to report immediately to the Security Officer upon term 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 of property of the U.S. Government.

Please initial: I am am not a U.S. Citizen. SIGNATURE OF APPLICANT:

APPLICANT WILL NOT WRITE BELOW THIS LINE

(PRIME CONTRACTOR USE ONLY)

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 and acknowledgement of loss report before a new badge will be issued.

FOR CONTRACTORS OR NON-APPROPRIATED FUND CONTRACTOR OR BADGE APPLICATION: 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 UNITED STATES.

SIGNATURE OF PRIME CONTRACTOR:

SUPERVISOR’S SIGNATURE: SUPERVISOR’S NAME (Printed): DATE:

COMPANY/ORGANIZATION: PHONE (Area Code):

GOVERNMENT HOST / CONTRACTING OFFICER ENDORSEMENT

FROM (Government Liaison/POC): ORGANIZATION:

TO (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.

START DATE: EXPIRATION DATE:

SIGNATURE (Government Liaison/POC): RANK AND / OR TITLE: DATE: PHONE:

SECURITY PASS / ID OFFICIAL USE ONLY

NOT VALID WITHOUT SECURITY SEAL AND MARK

PASS ISSUED BY: DATE OF ISSUE:

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 wrongful 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 imprisoned not more than five years, or both.

CNRSE 5200.1 Form 2 kena.k.montgomery Polygon kena.k.montgomery Rectangle