Access_Credential_Application.pdf

West Point Local Area Credential Application

Privacy Act Statement Authority HSPD-12:

Principal Purpose: to record names, signatures and other identifiers for the purpose of validating he trustworthiness of individuals requisition access to West Point, New York. Records may be maintained in both electronic and paper form.

Routine Uses: None Disclosure: Disclosure of the information is voluntary however, failure to provide any of the requested information my impede, delay or prevent further processing of this request. USMA Form 13-16

Local Area Credential Requested: Alumni Guest Contractor Delivery

Administrative Data Last Name: _________________________ First Name: ____________________________ MI: ____

Gender: Male Female Other SSN: _______-______-_______

Driver’s License Number: ____________________________________ State: __________________

Current Street Address: _____________________________________________________________

City: ______________________________________ State: ___________ Zip Code: _____________

Phone Number: ______________________ Email Address: ________________________________

Height: ________ Weight: ________ Hair Color: __________ Eye Color: _________

Contractor/Sponsor Information Project/Contract: ___________________________________________________________________

Employer: _____________________________ Supervisor: _________________________________

Sponsor Information: ______________________________ COR: ____________________________

COR Phone Number: _______________COR Email Address: _______________________________

Criminal History Have you been convicted of a crime in the past 10 years: Yes No Don’t Know

If Yes, what type: Misdemeanor Felony Other Don’t Know

If Yes, explain: ____________________________________________________________________

For Administrative Use Only Received By: _______________________________ Received Date: ______________

NCIC Date: _______________ NCIC Request #: ___________________ Badge Issued: Yes No

If No Why: ________________________________________________________________________

If Yes- Issue Date: __________ Expiration Date: __________ Badge #: ____________