Form 6006 Form 6006 Facility Access Media (FAM) Request

OMB Control No.: 3095-0057
Expiration date: 06/30/20XX

Facility Access Media (FAM) Request
Note: Instructions for completing form are in NARA 275, Background & Identity Verification Process for Access Privileges

(To be completed by requesting official, NOT the candidate)
1. Replacement card:

Yes

No

1a. Reason for replacement:

2. Background investigation completed:

Yes Type:

3. Does candidate need access to NARANet?

Damaged

Date:

Yes

Lost

No

Expired

Unknown

No

4. NARA office information (about candidate):
Position/title:
NARA office code: A
Duty phone:
NARA email address (if applicable):
Work email address (if applicable):
Duty location (name/address):

Classified contract:
Yes
No
Classified contract #:
Clearance level required:
Current clearance level held:
Date clearance expires:
NOTE: Classified contract listed in visitor log only

5. Candidate affiliation (check all that apply):
Foreign National

NARA employee

Contractor

Volunteer

Foundation

Intern

Other

If other, explain:
6. Candidate data:
Name (last, first, middle)

Name Suffix (Jr., Sr., III., etc…)

SSN

Name aliases (maiden name or any other applicable)
DOB (mm/dd/yyyy)
Hair color

Place of birth (country, state, city)
Eye color

Home address (city, state, zip)

7. Candidate agency role:
Building manager

Country of citizenship

Height

Weight

Personal phone

Personal email address

Not applicable

OIG special agent

Public affairs official

Safety official

Security official

Federal emergency response official
8. Candidate access:
Explain required access areas needed (e.g., offices, stacks, labs, etc)
Request 24-hour building access?
Yes
No
9. If candidate is not a NARA staff member, then which Federal agency, or if contractor, firm’s name:
Agency:
Firm:
10. Term employee:

Yes

No If yes, expected departure date (mm/dd/yyyy):

11. NARA official requesting issuance of FAM:
Name (last, first/MI):
Office code:

Duty phone:

Work email:

A

Signature:

Date (mm/dd/yyyy):

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

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

PRINT

Page 1 of 2

RESET

NA Form 6006 (02-19)
Required by NARA 275

SAVE

OMB Control No.: 3095-0057
Expiration date: 06/30/20XX

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 Facility Access Media 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 (MP), 8601 Adelphi Road,
College Park, MD 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

Page 2 of 2

NA Form 6006 (02-19)
Required by NARA 275