Attachment 2: Badge Request

45 SFS CREDENTIAL REQUEST FORM

(SUBJECT TO THE PRIVACY ACT OF 1974)

PRIVACY ACT STATEMENT

AUTHORITY: E.O. 9397; The Privacy Act of 1974, 5 U.S.C. 522a; DODD 8500.1 PRINCIPAL PURPOSE(S): To provide necessary information to determine if applicant meets installation access control requirements IAW HSPD12, DoD 5200.8, DTM 09-12, FIPS201 and AFMAN 31-113. Use of SSN is necessary to make positive identification of an applicant. Records in the Defense Biometric Identification System (DBIDS) are maintained to support DoD physical security and information assurance programs and are used for identity verification purposes, to record personal property registered with the DoD and for producing facility management reports. SSN, Driver’s License Number or other acceptable identification will be used to distinguish individuals who request access to SLD 45 property.
DISCLOSURE: Voluntary. However, failure to provide the requested information may result in denial of an access credential and denial of access to SLD 45 property

REQUIRES ACCESS TO:

Patrick SFB
Cape Canaveral SFS

TYPE

Govt Employee

LONG TERM

VSFB

Govt Contractor

SHORT TERM

(60 days or more)

Visitor

Volunteer

(59 days or less)

Student

Caretaker

Housing

I. VISITOR’S INFORMATION

NAME(First, Middle Initial, Last)

DRIVER’S LICENSE NUMBER

STATE

BIRTH(MM/DD/YYYY)

SOCIAL SECURITY NUMBER

COMPANY/UNIT

PERMANENT RESIDENT (GREEN CARD HOLDER)

YES

US CITIZEN?

YES

NO

ALIEN/PASSPORT NUMBER/COUNTRY OF

BIRTH(non-US Citizens)

GENDER

HEIGHT(ft/In)

NO

WEIGHT(lbs)

EYE COLOR

Does Applicant have a valid Federally Issued Common Access Card (CaC)?

YES

HAIR COLOR

NO

Contract end date/ Contract number (if applicable)

II. ORGANIZATION/SPONSOR AND ACCESS DATES/TIMES

START DATE(MM/DD/YYYY)

DAYS REQUESTING ACCESS

MON

END DATE(MM/DD/YYYY)

TUE

WED

THU

FRI

SAT

Hours
(e.g.
07301630)

REQUESTOR/SPONSOR

AGENCY/ORGANIZATION

DUTY PHONE

BADGING OFFICIAL/SPONSOR SIGNATURE

DATE

REMARKS

III. Security and Safety Training (CCSFS ONLY)
Scan the QR Code to access/complete the training and answer the questions.

Dial 911 (853-0911 cell phone) to report any emergency.

IV. ACKNOWLEDGEMENT OF INSTALLATION DRIVING PROCEDURES:

V. 45 SFS USE ONLY

ON SRBW

YES

DATE OF NCIC CHECK

NO

NCIC OPERATOR

COMMENTS

INITIALS

SUN

INSTRUCTIONS FOR COMPLETING CREDENTIAL REQUEST FORM (Must be typed or printed clearly in ink).

Directions for Submitting:
CCSFS: Page one (1) of this form may be: 1) hand delivered by the badging official, 2) faxed to the CCSFS Visitor Center at (321) 853-3441 or 3) emailed to [email protected]. Allow three (3) duty days for processing.