Attach_J-L _Picture_badge_writablea.pdf

NASA SECURITY RECORDS SYSTEM PRIVACY ACT NOTICE

Pursuant to Public Law 93-579 (Privacy Act of 1974), the following statement is furnished to individuals supplying information for inclusion of the

NASA Security Records System.

AUTHORITY.

42 USC 2165, 2455; 5 USC 1303, 1304, and 3301: 22 USC 1434 and 2585: 5 CFR 5.2: Executive Orders 9397, 10450, 10865, and 12065.

PURPOSES AND USES.

The principal purpose for collecting this information is to provide the data necessary to initiate investigations to determine your suitability for employment in the Federal service or for other purposes relating to employment in or contractual service for the Federal government, such as obtaining a security clearance: making a security area access determination, and evaluating qualifications, suitability, and loyalty to the U.S.

Government. This information may be disclosed to Federal, State, local, or foreign law enforcement agencies in the course of administrative or criminal investigations: to NASA officials and contractors, as appropriate: or for other routine uses as published in the system notice.

EFFECTS OF NONDISCLOSURE.

Supplying the information is voluntary on your part. However, if you do not furnish the information, the processing of your case will be suspended, and you will receive no further consideration. If you furnish only part of the information required, the processing of your case will be attempted, however, it may be significantly delayed. If the information withheld is found to be essential to processing your case properly, you will be so informed, and your case will receive no further consideration unless you supply the missing information. Although no penalties are authorized if you do not supply the information requested, failure to supply such information could result in your not being considered for employment: not being granted a security clearance, being denied access to security areas: or in your being terminated from employment based upon information available in the record. A false answer to any question is punishable by law (Title 18, United States Code, Section 1001).

INSTRUCTIONS

Use of this form is mandatory for all KSC Picture badges.

Send all requests to Visitor Records Center.

KSC FORM 20-162V2 NS (PA) (REV. 12106) PREVIOUS EDITIONS ARE OBSOLETE

REQUEST FOR KSC PICTURE BADGE

(Instructions on Reverse)

Foreign National Visitor No.

To:

JOHN F. KENNEDY SPACE CENTER, NASA

ATTENTION: KSC SECURITY OFFICE (SGSNRC)

KENNEDY SPACE CENTER, FLORIDA 32899

Date

From: (Name, Address, and Telephone No. of Employee's Organization) Contract Number

Issuing Agency or Company

Contract Exp. Date

Classified

❑ Yes ❑ No

Employee's Name (Last, First, Middle) Social Security Number Citizenship

Employee's Home Address (Street, City, State, Zip Code)

Date of Birth Place of Birth (City County, State, Country) Naturalization Alien Registration

Height Weight Hair Color Eye Color Date(s) of Visit

Name & Mail Code of NASA Sponsor or Contractor Badging Official Phone Signature of NASA Sponsor or Contractor Bating Official

Badge Type

ID Civil Servant ❑ Foreign National

❑ Contractor ❑ Media

LI Detailee

NASA Interin (CO-OP)

LI Docent

Center Specific Badges

❑ Center Activity ❑ Retiree

❑ Construction ❑ Tenant

❑ Day Care LI Tenant Contractor

❑ Emergency Response LI Vendor

Badge Expiration (for VEC use)

Month Year

Has a valid or expired KSC or CCAFS Badge at present ❑ Yes ❑ No

Badging Office Use Only 1

Badge Justification

Screened By

UUPIC #

X500#

One NASA Certification:

Personal Information

Company Primary:

In Lenel (CBACS)

Notified Badging

Temporary Pass:

Remarks

Entered

❑ Yes

System (Enter

Official ❑

❑ Yes

Yes ❑ No

❑ No

Badge Number, Enter Company): ❑ Yes ❑ No

Left Message ❑ Emailed ❑ Verbal

❑ No

KSC FORM 20-162V2 NS (PA) (REV. 12106) PREVIOUS EDITIONS ARE OBSOLETE

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