Form AD-1197 Request for USDA Identification (ID) Badge

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Request for USDA Identification (ID) Badge
Privacy Notice: Public Laws 95-113 and 93-579 permit collection of the data requested on this form. The information is used to determine eligibility for the issuance of USDA Identification
Badges. The information will be used to identity proof and register applicants as part of the Personal Identity Verification process. Providing this information is voluntary; however, failure
to submit this information may result in denial of a USDA Identification Badge.

A. Source Document Confirmation
1. Replacement ID Badge?
No
2. BI* Application Complete?

(To be completed by Human Resources)

Reason for Replacement:

Yes
Yes

(required for new cards only)
[*"BI" is a generic reference to all investigations for federal employment purposes]

Applicant Information
3. Compliant ID Badge:

Federal Employee

Law Enforcement/Physical Security

Contractor

Press Corp

Foreign National

Affiliate

3a. Non-Compliant ID Badge:

Site

Temporary

4. Name:

Retiree

3b. Expiration Date (mm/dd/yyyy):

8. Organization:

5. Phone:

10. SSN:

9. Work Address:

6. Position:

10. City:

7. Birth Date (mm/dd/yyyy):

13. Email:

Identity Source Document 1

(Attach copy)

11. State:

Identity Source Document 2

14. Name:

19. Name:

15. Doc. #:

20. Doc. #:

16. Doc Title:

21. Doc Title:

17. Issuer:

22. Issuer:

18. Doc. Expiration Date

(mm/dd/yyyy):

12. Zipcode:

(Attach copy)

23. Doc. Expiration Date (mm/dd/yyyy):

B. USDA Identification Badge Request (To be completed by Sponsor)
Sponsor Information
24. Name:

27. Email:

25. Phone:

27a. Access Required:

26. Organization:

I agree to sponsor the above application for a USDA Identification Badge and
certify that the information is accurate to the best of my knowledge.
28. ____________________________________________________________ 29.

Date ____/____/_____
(mm/dd/yyyy)
(To be completed by Registrar for new USDA ID badges ONLY, after Section A & B are
completed)

PRINTED NAME OF SPONSOR

C. Issuance Approval

SIGNATURE

Registrar Information

FBI Fingerprint Check/NAC Results

30. Date Completed

33. Name:

(mm/dd/yyyy):

31. Successfully adjudicated?
32. Comments:

34. Organization:
Yes

No

35. Phone:
36. Email:

37. I hereby certify that the information regarding the above applicant is accurate to the best of my
knowledge. I hereby
approve
do not approve this application for USDA Identification Badge
issuance.
38. ____________________________________________________________ 39.
PRINTED NAME OF REGISTRAR

SIGNATURE
Page 1 of 2

Date

____/____/_____
(mm/dd/yyyy)

D. USDA Identification Badge Details
completed)

(To be completed by Issuer, after Section A, B [and C, if required] is

Badge Information

Issuer Information

40. Name on Badge:

43. Name:

41. Badge Identifier:

44. Organization:

42. Badge Expiration Date

(mm/dd/yyyy):

45. Phone:
46. Email:

I hereby acknowledge issuance of a USDA Identification Badge to the applicant identified
above based on verification of the applicant's identity and verification of the above Registrar's
issuance approval.
47. ____________________________________________________________ 48.
PRINTED NAME OF ISSUER

E. Applicant Acknowledgement

Date

SIGNATURE

____/____/_____
(mm/dd/yyyy)

(To be completed by Applicant, after Section D is completed)

I, the Applicant, confirm receipt of the USDA Identification Badge identified above and that the
information is accurate to the best of my knowledge.
49. ____________________________________________________________ 50.
PRINTED NAME OF APPLICANT

SIGNATURE

Date

____/____/_____
(mm/dd/yyyy)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information is 0505-0022. The time required to complete this collection of information is estimated to average .25 hours per response, including the time for
reviewing instructions searching existing data sources, gathering and maintaining the data needed and completing and reviewing the form. (e) Agency Requirements.--Each agency that
maintains a system of records shall-- (1) maintain in its records only such information about an individual as is relevant and necessary to accomplish a purpose of the agency required to
be accomplished by statute or by executive order of the President; (2) collect information to the greatest extent practicable directly from the subject individual when the information may
result in adverse determinations about an individual's rights, benefits, and privileges under Federal programs; (3) inform each individual whom it asks to supply information, on the form
which it uses to collect the information or on a separate form that can be retained by the individual-- (A) the authority (whether granted by statute, or by executive order of the President)
which authorizes the solicitation of the information and whether disclosure of such information is mandatory or voluntary; (B) the principal purpose or purposes for which the information is
intended to be used; (C) the routine uses which may be made of the information, as published pursuant to paragraph (4)(D) of this subsection; and (D) the effects on him, if any, of not
providing all or any part of the requested information.
PRIVACY ACT ROUTINE USE 1. To the Department of Justice when: (a) the agency or any component thereof, or (b) any employee of the agency In his or her official capacity; or (c)
any employee of the agency In his or her Individual capacity where the Department of Justice has agreed to represent the employee; or (d) the UnitedStates Government, is a party to
litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records by
the Department of Justice Is therefore deemed by the agency to be for a purpose that Is compatible with the purpose for which the agency collected the records. 2. To a court or
adjudicative body In a proceeding when: (a) the agency or any component thereof, or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in
his or her individual capacity where the Department of Justice has agreed to represent the employee: or (d) the United States Government, is a party to litigation or has interest in such
litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records is therefore deemed by the agency
to be for a purpose that is compatible with the purpose for which the agency collected the records. 3. Except as noted in question 24, when a record on its face, or in conjunction with
other records, indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute, particular program statute,
regulation, rule, or order issued pursuant thereto, the relevant records may be disclosed to the appropriate Federal, foreign, State, local, tribal, or other public authority responsible for
enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, or order. 4. to any source or potential source from which
information is requested in the course of an investigation concerning the hiring or retention of an employee or other personnel action, or the issuing or retention of a security clearance,
contract, grant, license, or other benefit, to the extent necessary to identify the individual, inform the source of the nature and purpose of the investigation, and to identify the type of
information requested. 5. To a Federal, State, local, foreign, tribal, or other public authority the fact that this system of records contains information relevant to the retention of an
employee, or the retention of a security clearance, contract, license, grant, or other benefit. The other agency or licensing organization may then make a request supported by written
consent of the individual for the entire record if it so chooses. No disclosure will be made unless the information has been determined to be sufficiently reliable to support a referral to
another office within the agency or to another Federal agency for criminal, civil, administrative, personnel, or regulatory action. 6. to contractors, grantees, experts, consultants, or
volunteers when necessary to perform a function or service related to this record for which they have been engaged. such recipients shall be required to comply with the Privacy Act of
1974, as amended. 7. To the news media or the general public, factual information the disclosure of which would be in the public interest and which would not constitute an unwarranted
invasion of personal privacy. 8. To a Federal, State, or local agency, or other appropriate entities or individuals, or through established liaison channels to selected foreign governments,
in order to enable an intelligence agency to carry out its responsibilities under the National Security Act of 1947 as amended, the CIA Act of 1949 as amended, Executive Order 12333 or
any successor order, applicable national security directives, or classified implementing procedures approved by the Attorney General and promulgated pursuant to such statutes, orders
or directives. 9. To a Member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about
whom the record Is maintained. 10. To the National Archives and Records Administration for records management inspections conducted under 44 USC 2904 and 2906. 11. To the
Office of Management and Budget when necessary to the review of private relief legislation.

Form No. AD-1197 (Sept. 2005)

Page 2 of 2

OMB Control #:0505-0022