Section L Appendix 1 KSC Form 28-889 Visitor Badge Request.pdf

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KSC Visitor Badge Request (Multiple)

NRRS 1620.105.A

Page of KSC FORM 28-889 NS (PI) 08/13 (1.1) PREVIOUS EDITIONS ARE OBSOLETE. Validate prior to use.

Fax No. 867-4854 Mail Code: KSC Badging Office Phone No. 867-7763 Through signature above I attest to the validity and purpose of this visit.

FULL NAME (Last, First, MI)

COUNTRY OF CITIZENSHIP

SSN/Passport/Naturalization # or Alien Reg. # (Green Card) COMPANY NAME and ADDRESS

DATE OF BIRTH

PLACE OF BIRTH

START DATE

END DATE

To Be Escorted Y/N WARNING. When filled in, this form contains Personally Identifiable Information (PII) that is subject to Federal law and regulation. PII may be used only as authorized, which includes securing it in accordance with NASA policy and procedural requirements. Penalties for misuse apply.

Report suspected misuse immediately to Security Operations Center at 877-NASA-SEC (627-2732).

05/05/14 05/05/14 05/05/14 05/05/14 05/05/14 05/05/14 05/05/14 05/05/14 05/05/14 9.0.0.2.20101008.1.734229 KSC Visitor Badge Request (Multiple) KSC FORM 28-889 Rev 08/13, Created 08/13 Version 1.1 08/13 KSC Forms KSC Visitor Badge Request (Multiple) 08/13 1.1