PWS Attachment 5 - DRAFT Request for Common Access Card.pdf

Request for DoD Common Access Card Trusted Associate Sponsorship System Registration Please read Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this form

SECTION I

FSO Name:

Email Address:

Company:

Contract Order Number:

(13-digits only - see instructions for format)

Contract Expiration Date:

(Include option years. Date not to exceed 3 years or the Contract End Date)

SECTION II

DHA Approving Official (COR, Task Manager or Technical Rep)

Name:

Email Address:

DHA Approving Official Signature

SECTION III

LAST NAME FIRST NAME MI SSN DOB

(MM/DD/YYYY)

POB (ABBR.) or

COUNTRY EMAIL ADDRESS

SECTION IV

Authorized Mission Assurance Personnel Only

I verify the individual(s) listed have an open background investigation at OPM and have favorable fingerprint results from the FBI.

I verify the individual(s) listed have been vetted and determined to have a current DoD equivalent investigation.

Name Signature Date

DHA Form 33 Revised November 2013

DRAFT

Privacy Act Statement This statement serves to inform you of the purpose for collecting personal information required by this form and how it will be used.

AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; DoD Directive

1000.25, DoD Personnel Identity Protection (PIP) Program; DoD Instruction 1341.2, Defense

Enrollment Eligibility Reporting System (DEERS) Procedures; Homeland Security Presidential

Directive 12: Policy for a Common Identification Standard for Federal Employees and

Contractors; and E.O. 9397 (SSN), as amended.

PURPOSE: To apply for a DoD Common Access Card (CAC) in the Trusted Associate Sponsorship System

(TASS) and/or Defense Enrollment Eligibility Recording System (DEERS) and to control access to, and movement within, DoD installations, buildings, facilities, computer systems, and/or computer networks.

ROUTINE USES: Collected information may be used to research investigations in the Joint Personnel

Adjudication System (JPAS) and/or Personnel Investigative Processing System (PIPS) and to process CAC applications of individuals in the TASS. Information may also be provided to other Federal agencies to authenticate the identity of individuals who, in the conduct of official business, present the CAC as proof of identity to gain physical or logical access to government and contractor facilities, locations, networks, or systems. Information may be used and disclosed in accordance with 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, which incorporates the DoD “Blanket Routine Uses” published at: http://dpclo.defense.gov/privacy/

SORNs/blanket_routine_uses.html.

DISCLOSURE: Voluntary. However, failure to provide information may result in the denial of a CAC application and no access to DoD computer systems, networks installations, buildings, and/or facilities.

DHA Form 33 (Back)

Instructions for Completion of DHA Form 33, Request for DoD Common Access Card

Trusted Associate Sponsorship System Registration Industry Facility Security Officers:

• Complete the DHA Form 33, in its entirety (The form must be typed)

• Secure the form to the DHA Authorizing Official a Contractor Officer Representative (COR), Task Manager (TM) or Technical Representative (TR), for approval

DHA Approving Official (COR, TM or TR):

• Verify the applicants identified on the DHA Form 33, requires a Common Access Card (CAC), for access to DoD facilities and DoD networks onsite or remotely

• Verify the contract order number

(Format is 13-characters consisting of the DODAAC (6 char alphanumeric), fiscal year (2 char numeric), procurement type code (1 char alphabetic) and serialized identifier (4 char alphanumeric))

• Verify the contract expiration date (CACs will be issued for a period not to exceed 3 years from the date of issuance or contract expiration date, whichever is shorter)

(Example: a contract with a base year plus 2 option years would be issued a CAC with 3 year expiration)

• Digitally or manually sign the form

• Fax signed form to (703) 681-5207, Attn: TASS/CACB

Trusted Agent (TA):

• Verify that an FBI fingerprint check with favorable results has been completed and a National Agency Check with inquires (NACI), or a DOD determined equivalent investigation, or greater, has been submitted to the Office of Personnel Management (OPM)

• Sign and date the DHA Form 33

• Process form in the Trusted Associate Sponsorship System (TASS)

DHA Form 33 (Instructions) Revised November 2013