W911SD-19-R-0092_SITE_VISIT_LAC_Transfer_Station_Closure.pdf

West Point Local Area Credential Application

Local Area Credential Requested: Ƒ Alumni Ƒ Guest Ƒ Contractor Ƒ Delivery

Administrative Data

Last Name: First Name: MI:

Gender: Ƒ Male Ƒ Female Ƒ 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: Ƒ Yes Ƒ No Ƒ Don’t Know

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

If Yes, explain:

For Administrative Use Only

Received By: Received Date:

NCIC Date: NCIC Request #: Badge Issued: Ƒ Yes Ƒ No

If No Why: If

Yes- Issue Date: Expiration Date: Badge #:

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