Form DD Form 2249 DD Form 2249 DoD Building Pass Application

OMB No. 0704-0328

DOD BUILDING PASS APPLICATION

OMB approval expires

(PERMANENT)

The public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0704-0328). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with
a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE BUILDING PASS OFFICE
TO WHICH YOU ARE APPLYING.
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301; EO 12356; EO 9397.
PRINCIPAL PURPOSES: To facilitate verification of background investigations for individuals applying for access to DoD buildings in connection
with their official duties.
ROUTINE USES: Information may be furnished to Federal, state, or local agencies for regulatory and law enforcement purposes.
DISCLOSURE: Voluntary; however, refusal to furnish requested information may result in inability to verify essential personal information and
approve requested building pass application.
1. NAME OF APPLICANT
a. LAST

b. FIRST

c. MIDDLE
INITIAL

2a. SOCIAL SECURITY
NUMBER

b. DATE OF BIRTH
(YYYYMMDD)

3. BACKGROUND INVESTIGATION DATA
YEAR
(1)

MONTH
(2)

YEAR
(1)

MONTH
(2)

b. NATIONAL AGENCY CHECK OR
SPECIAL AGENCY CHECK
COMPLETED

a. BACKGROUND INVESTIGATION
COMPLETED
4. EMPLOYMENT CATEGORY (X one)
a. GOVERNMENT

c. CONTRACTOR

b. FOREIGN

d. PRESS

e. DOES THE APPLICANT NEED TO
ESCORT OTHERS TO PERFORM
HIS OR HER DUTIES? (X one)

(1) ESCORT
(2) NO ESCORT

5. BUILDING ACCESS REQUESTED (X one)
a. PENTAGON

c. OTHER (Specify)

(1) 24 HOUR ACCESS
d. ACCESS HOURS
(X one)

b. NCR
(Complete Item 6)

(2) BUSINESS HOURS ONLY

6. JUSTIFICATION FOR NCR ACCESS (List buildings which require 24/7 access.)

D R A F T

7. PASS INFORMATION
a. EXPIRATION DATE OF
NEW PASS (YYYYMMDD)

b. REASON FOR ISSUANCE (X one)
(1) INITIAL ISSUE

8. AUTHORIZED/REQUESTING OFFICIAL
a. NAME (Last, First, Middle Initial)

(2) RENEWAL

b. TELEPHONE NUMBER (Include area code)

c. SIGNATURE

DD FORM 2249, 20081031 DRAFT

(3) NAME CHANGE

d. DATE SIGNED (YYYYMMDD)

PREVIOUS EDITION IS OBSOLETE.

Reset

Adobe Professional 8.0

DOD BUILDING PASS APPLICATION

(TEMPORARY/NCIC REQUEST)
9. NAME OF APPLICANT
a. LAST

10. SOCIAL SECURITY NUMBER

b. FIRST

c. MIDDLE INITIAL

11a. DATE OF BIRTH (YYYYMMDD)

b. COUNTRY

12. PHYSICAL DESCRIPTION (This data is requested for identification purposes only, and is not a factor in determining eligibility.)
a. RACE (Mark one or more)
(1) AMERICAN INDIAN OR ALASKA NATIVE

(4) HISPANIC OR LATINO

(2) ASIAN

(5) NATIVE HAWAIIAN OR
OTHER PACIFIC ISLANDER

D R A F(6) WHITE
T

(3) BLACK OR AFRICAN AMERICAN

c. HEIGHT (Inches)

b. SEX (X one)
(1) MALE

d. WEIGHT (Pounds)

(2) FEMALE
c. IF "NO," INDICATE IMMIGRATION NUMBER AND
COUNTRY

13. IS APPLICANT A U.S. CITIZEN? (X one)
a. YES

(7) OTHER

d. EXPIRATION DATE
(YYYYMMDD)

b. NO

14. BACKGROUND INVESTIGATION DATA
YEAR
(1)

MONTH
(2)

INITIALS
(3)

a. BACKGROUND INVESTIGATION
(BI) INITIATED
b. NATIONAL AGENCY CHECK (NAC)/
SPECIAL AGENCY CHECK (SAC) INITIATED
c. BI COMPLETED
d. NAC/SAC COMPLETED
e. NCIC COMPLETED
15. EMPLOYMENT CATEGORY (X one)
a. GOVERNMENT

c. CONTRACTOR

(1) 24 HOUR
e. ACCESS HOURS
(X one)

b. PRESS

d. PENTAGON RENOVATION

(2) BUSINESS HOURS ONLY

16. BUILDING ACCESS REQUESTED (X one)
c. DOES THE APPLICANT NEED
TO ESCORT OTHERS TO
PERFORM HIS OR HER
DUTIES? (X one)

a. PENTAGON
b. OTHER (Specify)
17. PASS INFORMATION
a. EXPIRATION DATE OF NEW PASS
(YYYYMMDD)

(1) ESCORT
(2) NO ESCORT

b. REASON FOR ISSUANCE (X one)
(1) INITIAL ISSUE

18. AUTHORIZED/REQUESTING OFFICIAL
a. NAME (Last, First, Middle Initial)

c. SIGNATURE

DD FORM 2249 (BACK), 20081031 DRAFT

(2) RENEWAL

(3) NAME CHANGE

b. TELEPHONE NUMBER (Include area code)

d. DATE SIGNED (YYYYMMDD)

Reset