ID_RequestAccess_Form-01_1400_(scanned).pdf

National Gallery of Art Washington, DC 20565

I.D. REQUEST and ACCESS FORM

PART I. Personal Data

Last Name: First Name: Middle Name:

SSN: DOB: Eyes: Hair: Height: Weight:

Sex: Other Names Used:

Home Address (Street, RD#, PO Box, etc) City

State: Zip: Home Phone: Cell Phone: E-mail:

Emergency Contact Information

Contact: Day Phone: Night Phone:

Job Information

Department: Work Phone: Work Hours: Title:

PART II. For Contractors, Volunteers, and Other Non-Gallery Employees

Company: COTR/Sponsor: COTR/Sponsor Phone:

Project, Contract or Term Completion Date (if unknown, enter estimated date):

PART III. A. Authorization

ID Access Badge

G Approved

G Disapproved

Department/Division Head’s Name:

Signature: Date:

PART III. B. Art Access Authorization

Art Access

G Approved

G Disapproved

Registrar’s Name:

Signature: Date:

PART IV. Certification

I, the undersigned, understand this badge is the property of the National Gallery of Art and must be returned upon expiration or end of association with the Gallery (e.g., termination of employment, project or contract completion) and upon request must be surrendered to Gallery security personnel. I further agree to display this badge in plain view on my person while on the premises of the National Gallery of Art.

Badge Holder Signature: _______________________________________ Date: ____________________

Revised April 2006

SEE REVERSE SIDE FOR GENERAL INSTRUCTIONS

GENERAL INSTRUCTIONS

ID REQUEST and ACCESS FORM

The information collected on this form is used to determine your level of security access to non-public space at the National Gallery of Art and/or issuance of a permanent Gallery Identification (ID) Badge.

This form must be completed for all first-time badge recipients and for all badge renewals and extensions.

When this form is submitted as part of Gallery Specifications Section 01 1400 (Work Restrictions) and/or

Contract Clause Security Restrictions, processing time for completion of security clearance will take up to seven (7) business days from notice of intent to work on site.

Part I: Personal Data

� Either type your responses on this form or print clearly in dark ink.

� All responses must be complete and truthful. Cell Phone number and E-Mail address are optional.

Part II: For Contractors, Volunteers, and Other Non-Gallery Employees

� This section should be completed by everyone except permanent Gallery employees.

� The Contracting Officer’s Technical Representative (COTR)/Sponsor is the Gallery employee responsible for the applicant (e.g., contractor, volunteer, other non-Galley employee).

� A date must be entered in the Project, Contract, or Term Completion Date field before a badge will be issued. Except for Docents and Art Information Volunteers, the date should not exceed one (1) year from the date the form is completed. Forms without a date entered in this field will be returned.

Part III. A. Authorization

� Before a Gallery badge is issued, approval must be granted by a Department or Division Head.

� The name of the Department or Division Head should be clearly printed in the space provided.

� The Department or Division Head must sign and date this form.

Part III. B. Art Access Authorization

� This section is to be completed only by the Registrar, who authorizes art access and the handling of art objects.

� The name of the Registrar should be clearly printed in the space provided.

� The Registrar must sign and date this form before an art access badge will be issued.

Part IV. Certification

� This form must be signed and dated by the badge recipient at the time the badge is issued.