Solicitation_Documention_Attachment_-_USMA_13-16_Local_Area_Badge.pdf

USMA FORM 13‐16

United States Military Academy

Application for Local Area Badge (LAB)

Local Area Badge (LAB) Requested (Check One):

☐ Contractor ☐ Visitor ☐ Delivery ☐ Guest (ODIA/AOG/AU‐Pair/GS‐Spouse/Other:______________) Administrative Data

Name (Last, First MI)_________________________________ Date of Birth (mm/dd/yy) ______________ SSN:_______________________ Drivers License Number:________________________ State:_________

Current Street Address:___________________________________ City:___________________________

State:_______ Zip Code:____________ Phone Number:________________________________________

E‐mail address:_________________________________________________________________________

HT:_______ Weight:_________ Hair:_________ Eyes:_________ Gender: ☐Male ☐Female ☐ Other

Contractor Information

Employer:_____________________________ Employer Phone:_________________________________

Supervisor:____________________________ Project:_________________________________________

COR:___________________________ COR PHONE:_________________COR E‐mail:_________________

Criminal History

1. Have you been convicted of a Crime in the past 10 Years? ☐YES ☐NO ☐I don’t know

If Yes what type of Crime: ☐ Misdemeanor ☐ Felony ☐ Other ☐ I don’t know.

If Yes, explain__________________________________________________________________________

Administrative ONLY:

Received By:______________________ Received Date:________________NCIC Date:______________

NCIC Request #:_________________ Badge Issued ☐YES ☐NO if NO why________________________

IF yes: Badge Issue Date:______________ Badge Expiration Date:_______________Badge #:__________

PRIVACY ACT STATEMENT

AUTHORITY: HSPD‐12

PRINCIPAL PURPOSE: To record names, signatures, and other identifiers for the purpose of validating the trustworthiness of individuals requesting access to West Point

Military Academy, NY. NOTE: Records may be maintained in both electronic and/or paper form.

ROUTINE USES: None.

DISCLOSURE: Disclosure of this information is voluntary; however, failure to provide the requested information may impede, delay or prevent further processing of this request.