PASS APPLICATION blank.pdf

COMNAVREGMIDLANT

COMMON ACCESS CARD/CONTRACTOR/BUSINESS PASS APPLICATION

COMNAVREGMIDLANT/SOPA (ADMIN)HRINST 5400.1

Type of Request: Base Contractor Regional Contractor CAC

Base Affiliate: ________________________________________________ Date:

Name: DOB:

Street Address: Place of Birth:

City: State: Zip: Social Security No.:

Telephone Number: ( ) Sex: Race: Age: Eyes: Hair: Wt: Ht:

CITIZENSHIP STATUS

U.S. NATIVE If Naturalized, If Derived, Parents DATE/PLACE/AND COURT CITIZEN Certificate No. Certificate No.(s)

Yes Yes No

IMMIGRANT REGISTRATION NATIVE PASSPORT/VISA DATE AND PORT OF ENTRY

ALIEN NO. COUNTRY

NO.

COUNTRY

POSITION WITH COMPANY: SIGNATURE OF APPLICANT:

Name: Telephone Number: ( )

Street Address: City: State: Zip:

1. Forwarded.

2. I hereby certify that the applicant is an employee of this company. If the applicant’s affiliation with this company is terminated, the access pass issued to him/her will be recovered by me or my designated representative and returned to the issuing office for cancellation, with reason for termination of affiliation. I am aware that if the applicant violates any Federal laws applicable to Navy reservations, Navy regulations, it may result in suspension of this company’s privilege to transact business on the Navy reservation.

SIGNATURE OF COMPANY OFFICIAL

From: Email:

(Sponsoring Command or Activity) To: Commander, Navy Region, Mid-Atlantic, Norfolk, VA 23511

1. Forwarded, recommending issuance of access pass to applicant, It is requested that the pass be valid for the period indicated: FROM: TO:

(Not to exceed 12 months).

2. Applicant’s company qualifies in accordance with COMNAVREGMIDLANT/SOPA (ADMIN)HRINST 5400.1 series to transact business/service. Endorsement must be signed by the Trusted Agent. Name and title must be typed or printed under signature.

Signature: Telephone No.: ( )

Name/Title:

CRIMINAL HISTORY

Date of Query: __________________

CCH VCIN CLEOC IAQ

Query Results:

Acceptable Unacceptable

Check completed by: __________________________________________________________

Remarks:

NCIS Investigation: ________________________________________________________________

FBI Number/SID Number Results: __________________________________________________

Comments:

Security Officer: ________________________________________ ____________________ (Signature) (Date)

NOTIFICATION

Name: ________________________________________ Date/Time: ___________________________ (Print Name)

By: Email: _________________________ Telephone: ______________________________

Notification By: ______________________________________ (Signature)

PRIVACY ACT NOTIFICATION

AUTHORITY: 5 U.S.C. Section 301; 10 U.S.C. Sections 1074(c)(1) and 1095(k)(2); 10 U.S.C. chapter 147; 50 U.S.C. chapter 23; E.O.

9397; E.O. 10450, as amended.

PRINCIPAL PURPOSES: To apply for the Common Access Card and/or DEERS Enrollment; control access to and movement in or on DoD installations, buildings, or facilities; regulate access to DoD computer systems and networks; and verify eligibility, if authorized for DoD benefits and privileges. To authenticate the identity of the authorizing/verifying official for security or auditing purposes.

ROUTINE USES: To Federal and State agencies and private entities, as necessary, on matters relating to utilization review, professional quality assurance, program integrity, civil and criminal litigation, and access to Federal government and contractor facilities, computer systems, networks, and controlled areas.

DISCLOSURE: Voluntary, however, failure to provide information may result in denial of a Common Access Card; non-enrollment in the Defense Enrollment Eligibility Reporting System (DEERS); refusal to grant access to DoD installations, buildings, facilities, computer systems and networks; and denial of DoD benefits if otherwise authorized.