Form 6006 Personal Identity Verification (PIV) Request

	OMB Control No.: 3095-0057 Expires: 05/31/2007 National Archives and Records Administration Personal Identity Verification (PIV) Request
A. PIV Request and Source Document Confirmation (To be completed by Sponsor)
1. Replacement Card? □ No □ Yes				1a. Reason for Replacement: _____________________________
2. Background investigation completed: □ No □ Yes				2a. If Yes, type/date completed: ____________________________ ______________________________________________________
3. Background investigation package completed? □ Yes
Applicant Information 4. Type: □ NARA employee □ Contractor □ Volunteer □ Foundation □ Intern □ Other
5. Name (Last, First, MI)					DOB		Hair Color	Eye Color		Weight	Height
I, the applicant, certify that the Applicant Information entered above is accurate to the best of my knowledge. 6. Applicant Signature: 7. Date (mm/dd/yyyy)
8. Applicant’s Position/Title:							13. Sponsor Information: Name: Office Code: Phone No:
9. Applicant’s NARA Office Code: 10. Applicant’s Work Phone:
11. Applicant Access [e.g., buildings, rooms]: 12. Federal Identity Card (FIC) to be valid until [mm/dd/yyyy]
I agree to sponsor the above applicant for a Federal Identity Card and certify that the information in section A is accurate to the best of my knowledge. 14. Sponsor Signature: 15. Date: [mm/dd/yyyy]
B. Identity Proofing (To be completed by Identity Processor)
16. Did applicant present two forms of identification, one of which was a photo ID issued by a state or the Federal Government? □ Yes 17. Copies of ID source documents attached? □ Yes							18. Identity Processor Information: Name: Office Code: Phone No:
19. Identity (ID) Source Documents Details
Document One: Type		Issuing Authority:				Document Number:			Expiration Date:
Document Two: Type		Issuing Authority:				Document Number:			Expiration Date:
I certify that the above Applicant appeared before me and presented two ID source documents that appeared to be genuine. 20. ID Processor signature: ­­­­­­­­­­­­­­­­­­­ 21. Date: [mm/dd/yyyy]

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION NA Form 6006 (Front)

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C. Card Approval (To be completed by registrar)
22. Based on: □ NAC □ NACI □ FBI Fingerprint Results
23. Date completed: [mm/dd/yyyy]	26. Registrar Information Name: Office Code: Phone No.:
24. Favorable? □ Yes □ No
25. Comments:
I hereby □ Approve □ Disapprove issuance of a Federal Identity Card to the above-named Applicant. 27. Registrar Signature: 28. Date: [mm/dd/yyyy]
D. Card Details (To be completed by Issuer after Section C has been completed)
29. Name on Card: 30. FIC Number: 31. Date Issued: [mm/dd/yyyy] 32. Card Expiration Date: [mm/dd/yyyy]	33. Issuer Information Issuer Name: Office Code: Phone No.:
I acknowledge issuance of a FIC to the Applicant identified above based on verification of the Applicant’s identity and the above Registrar’s issuance approval. 34. Issuer Signature: 35. Date: [mm/dd/yyyy]
E. Applicant Acknowledgement (To be completed by Applicant after Section D is completed)
I, the Applicant, confirm receipt of the FIC card identified above, verify that the information is accurate to the best of my knowledge, and agree to abide by all rules and responsibilities associated with the card.
36. Applicant Signature: 37. Date: [mm/dd/yyyy]
Upon completion, return this form to the Registrar
PRIVACY ACT STATEMENT In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information is authorized by 44 U.S.C. 2104. Disclosure of the information is voluntary. The information provided will be used to prepare and issue a credential or pass. Additionally, the information may be provided to an expert, consultant, or contractor of NARA to assist NARA in the performance of its duties. If some or any of the information is not provided by the contractor, the effect will be that the credential or pass may not be issued to the contractor and the contractor will be required to sign in and out of NARA-controlled buildings during normal working hours. If some or any of the information is not provided by the agency reviewer, the effect will be that the credential or pass may not be issued to the agency reviewer and the agency reviewer may not be allowed access to controlled-access data. In addition, neither contractors nor agency reviewers will be permitted to enter a NARA-controlled building during secure hours. PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Public burden reporting for this collection of information is estimated to be 3 minutes per response. Send comments regarding the burden statement or any other aspect of the collection of information, including suggestions for reducing this burden to the National Archives and Records Administration (NHP), 8601 Adelphi Road, College Park, MD 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION NA Form 6006 (Back)

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