Form 6006 Form 6006 Facility Access Media (FAM) Request

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OMB Control No.: 3095-0057
Expiration date: 06/XX/202X

Facility Access Media (FAM) Request
Note: Instructions for completing form are in NARA 275, Background & Identity Verification Process for Access Privileges
*All dates are formated as MM/DD/YYYY

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

Yes

No

1a. Reason for replacement:

2. Background investigation completed:

Yes

Lost

*Date:

Yes Type:

3. Does candidate need access to NARANet?

Damaged

No

Expired
Unknown

No

4. NARA office information (about candidate):
Position/title:

NARA Classified contract:

NARA office code:

NARA Classified contract #:

Yes

No

Duty phone {e.g. (301) 555-1212}:

Clearance level required:

NARA email address (if applicable):

Current clearance level held:

Work email address (if applicable):

*Date visit authorization:

Duty location (name/address):

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 Suffix (Jr., Sr., III., etc) SSN

Name (last, first, middle)

Name aliases (maiden name or any other applicable)
*DOB

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

Personal phone

Weight

Personal email address

Not applicable
OIG special agent

Public affairs official

Security official

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Federal emergency response official
NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

Safety official

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NA FORM 6006 (12-19)
REQUIRED BY NARA 275

OMB Control No.: 3095-0057
Expiration date: 06/XX/202X

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 candidate:

Yes

No *If yes, expected departure date:

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

Office code:

Duty phone {e.g. (301) 555-1212}:

Work email:

*Date:

Signature:

See below for the Privacy Act and Paperwork Reduction Act Public Burden Statements 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 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.
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NA FORM 6006 (12-19)
REQUIRED BY NARA 275