Form 6006 Form 6006 Identification Card Request

O MB Control No.: 3095-0057

Expiration date: XX/XX/20XX

National Archives and Records Administration Identification Card Request

A. Identification Card Request and Source Document Confirmation (To be completed by Sponsor)

1. Replacement Card: Yes No 1a. Reason for Replacement: Defaced Lost Expired

2. Background investigation completed: Yes No 2a. If Yes, type and date completed:      

3. Background investigation package completed? Yes No

Candidate Affiliation (check all that apply):

4. Type: Foreign National NARA employee Contractor Volunteer Foundation Intern Other

5. Name (Last, First, MI) DOB Hair Color Eye Color Height Weight

Last First MI [mm/dd/yyyy]                        

6. Agency:       Firm:       24 Hour Access? Yes No

7. Vehicle One: Make:       State:       Plate #:      

Vehicle Two: Make:       State:       Plate #:      

I, the candidate, certify that the Candidate Affiliation entered above is accurate to the best of my knowledge.

7. Candidate Signature: 8. Date: [mm/dd/yyyy]

9. Candidate’s Position/Title:       10. Candidate’s NARA Office Code:       11. Candidate’s Work Phone:       12. Candidate Access [e.g., buildings, rooms]:      

14. Sponsor Information: Name:       Office Code:       Phone No: (   )     -     

13. Identification Card to be valid until: [mm/dd/yyyy] 15. Parking Permit: Yes No

16. Brass Keys to Room #’s      

I agree to sponsor the above candidate for an Identification Card and certify that the information in Section A is accurate to the best of my knowledge.

17. Sponsor Signature: 18. Date: [mm/dd/yyyy]

B. Identity Proofing (to be completed by Identity Processor)

19. Requires two forms of identification attached (one of which is a photo ID issued to the candidate by a state or the Federal Government) 20. Identity (ID) Source Documents Details

21. Identity Processor Information: Name:       Office Code:       Phone No: (   )     -     

Document One: Type: Issuing Authority: Document Number: Expiration Date:

                       

Document Two. Type: Issuing Authority: Document Number: Expiration Date:

                       

I, the Identity Processor, certify that:

the above Candidate appeared before me and presented two ID source documents that appeared to be genuine.

a current NACI is on file for the above Candidate.

OR

I have issued a Temporary Building Pass to the above Candidate pending completion of a current NACI.

22. ID Processor signature: 23. Date: [mm/dd/yyyy]

I, ________________________________________ acknowledge receipt of a temporary building pass, pending completion of a background investigation.

24. _______________________________________ 25. Date: [mm/dd/yyyy]

Candidate signature

C. Card Approval (To be completed by registrar)

26. Based on: NACI Other 27. Date completed: [mm/dd/yyyy] 28. Favorable? Yes No 29. Clearances/Access:

30. Registrar Information Name:       Office Code:       Phone No. (   )     -     

General SEC SEC/L TS Q SCI SI TK G HCS NATO

I hereby Approve Disapprove issuance of an Identification Card to the above-named Candidate.

31. Registrar Signature: 32. Date: [mm/dd/yyyy]

D. Card Details (To be completed by Issuer after Section C has been completed)

33. Name on Card:       34. Date Issued: [mm/dd/yyyy] 35. Card Expiration Date: [mm/dd/yyyy] 36. Parking Permit #:      

37. Issuer Information Issuer Name:       Office Code:       Phone No.: (   )     -     

I acknowledge issuance of an Identification Card to the Candidate identified above based on verification of the Candidate’s identity and the above Registrar’s issuance approval.

38. Issuer Signature: 39. Date: [mm/dd/yyyy]

E. Candidate Acknowledgement (To be completed by Candidate after Section D is completed)

I, the Candidate, confirm receipt of the Identification 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.

40. Candidate Signature: 41. Date: [mm/dd/yyyy]

Upon completion, return this form to the Registrar

See the back of this form for the Privacy Act Statement and Paperwork Reduction Act Public Burden Statement that apply to the information you are providing.

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 an identification card 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 candidate, the effect will be that the identification card or pass may not be issued, resulting in the candidate being denied access to NARA facilities and IT systems.

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 (1-10)