Secnav 5512/1 Department Of The Navy Local Population Id Card/base Acc

OMB 0703-0061 05/31/2024

CUI (when filled in)

DEPARTMENT OF THE NAVY LOCAL POPULATION ID CARD/BASE ACCESS PASS REGISTRATION
PRIVACY ACT STATEMENT:
AUTHORITY: 10 U.S.C. 113, Secretary of Defense; DoD Directive 1000.25, DoD Personnel Identity Protection (PIP) Program; DoD Instruction 5200.08, Security of DoD Installations and
Resources and the DoD Physical Security Review Board (PSRB); DoD 5200.08-R, Physical Security Program; DoD Directive 5200.27, Acquisition of Information Concerning Persons and
Organizations not Affiliated with the Department of Defense (Exception to policy memos); Directive-Type Memorandum (DTM) 09-012, Interim Policy Guidance for DoD Physical Access
Control; DTM 14-005, DoD Identity Management Capability Enterprise Services Application (IMESA) Access to FBI National Crime Information Center (NCIC) Files; and E.O. 9397 (SSN),
as amended; OPNAVINST 5530.14E, Navy Physical Security and Law Enforcement Program; Marine Corps Order P5530.14, Marine Corps Physical Security Program Manual;
SORNNM05512-2 Badge and Access Control System Records and DMDC 16, Identity Management Engine for Security and Analysis (IMESA): http://dpcld.defense.gov/Privacy/
SORNsIndex
PURPOSE(S): To control physical access to Department of Defense (DoD), Department of the Navy (DON) or U.S. Marine Corps Installations/Units controlled information, installations,
facilities, or areas over which DoD, DON, or U.S. Marine Corps has security responsibilities by identifying or verifying an individual through the use of biometric databases and associated
data processing/information services for designated populations for purposes of protecting U.S./Coalition/allied government/national security areas of responsibility and information; to
issue badges, replace lost badges, and retrieve passes upon separation; to maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/exit times of
personnel.
ROUTINE USE(S): To designated contractors, Federal agencies, and foreign governments for the purpose of granting Navy officials access to their facility.
DISCLOSURE: Providing registration information is voluntary. Failure to provide requested information may result in denial of access to benefits, privileges, and DoD installations,
facilities and buildings.

IDENTITY PROOFING AND APPLICANT INFORMATION
1. LAST NAME:

2. FIRST NAME:

3. MIDDLE NAME:

4. NAME SUFFIX:
Jr.

5. RACE

AMERICAN INDIAN or ALASKA

(Check one or more):

NATIVE

6. GENDER
(Check

MALE

FEMALE

HISPANIC OR LATINO

BLACK or AFRICAN AMERICAN

ASIAN

8. CITY OF BIRTH:

7. DATE OF BIRTH:

Sr.

9. STATE OF BIRTH:

I

II

III

NATIVE HAWAIIAN
OR OTHER PACIFIC
ISLANDER

IV
WHITE

10. BIRTH COUNTRY:

one):

11. US CITIZEN (Check):

YES

NO

YES
NO
12. DUAL CITIZENSHIP:
CITIZENSHIP IF OTHER THAN US (Country) :

U.S. Citizen Minimum Documentation Required:
By Birth - Social Security No and/or State ID/Drivers License.
Naturalized - Certification Number, Petition Number, Date, Place and Court, United States passport number, Social Security No and/or State ID/Drivers
License.
Derived - Parent's certification number, Social Security No and/or State ID/Drivers License.
Alien Minimum Documentation Required:
Registration Number, Expiration date, Date of entry, Port of entry.
13. IDENTITY SOURCE
14. DOCUMENT
DOCUMENTS PRESENTED: NUMBER:

15. ISSUED BY
STATE/COURT:

16. ISSUED BY
COUNTRY:

Social Security No.

United States

State ID/Drivers License

United States

17. ISSUED:

18. EXPIRES:

Passport No.
Certification Number and
Petition Number

Derived - Parent's
Certification Number:

United States

Alien Registration No.

United States
Date of Entry:

Port of Entry:

OTHER APPROVED IDENTITY SOURCE DOCUMENTS:

19. WEIGHT
(Pounds):

20. HEIGHT
(Inches):

21. HAIR COLOR (Check one):
Blond

Brown

White

Silver

22. EYE COLOR (Check one):

Black
Auburn

Gray
Bald

Red

Brown
Black

Green

Blue

Gray

Violet

Hazel
Unknown

23. HOME ADDRESS (Include city, state, zip code):

HOME PHONE (Include Area Code):

24. BASE SPONSOR'S NAME:

SPONSOR PHONE (Include Area Code):

SECNAV 5512/1 (MAY 2021)

CUI (when filled in)

Controlled by: DoN
CUI Category: PRVCY
LDC: FEDCON
POC: Rodney Ramseur, [email protected], 202-433-4281

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OMB 0703-0061 05/31/2024

CUI (when filled in)
EMPLOYMENT ACTIVITY INFORMATON
25. EMPLOYER NAME AND ADDRESS (Include city/state/zip code):

EMPLOYER PHONE (Include Area Code):

26. SUPERVISOR NAME AND ADDRESS (Include city/state/zip code):

SUPERVISOR PHONE(Include Area Code):

27. Check the applicable box for WORK HOURS box or check the OTHER box and enter the work hours, then check the applicable box for WORK DAYS:
WORK HOURS:

0600-1800

0800-1700

OTHER

WORK DAYS:

SN

M

T

W

TH

F

ST

PRIOR FELONY CONVICTIONS
28. Have you ever been convicted of a Felony?

YES

NO

Initial

REQUIREMENT TO RETURN LOCAL POPULATION ID CARD
29. I understand that I am required to return my Local Population Identification Card to the Base Pass Office when it expires or if my employment is
terminated for any reason.
(initial)
AUTHORIZATION AND RELEASE AND CERTIFICATION
30. I hereby authorize the DOD/DON and other authorized Federal agencies to obtain any information required from the Federal government and/or
state agencies, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense Security Service (DSS), the U.S. Department of
Homeland Security (DHS).
I have been notified of DON right to perform minimal vetting and fitness determination as a condition of access to DON installation/facilities. I
understand that I may request a record identifier; the source of the record and that I may obtain records from the State Law Enforcement Office as may
be available to me under the law. I also understand that this information will be treated as privileged and confidential information.
I release any individual, including records custodians, any component of the U.S. Government or the individual State Criminal History Repository
supplying information, from all liability for damages that may result on account of compliance, or any attempts to comply with this authorization. This
release is binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this authorization
that show my signature are as valid as the original release signed by me.
FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD RESULT IN FINES AND/OR IMPRISONMENT UP TO FIVE YEARS.
BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE YOU HAVE ANSWERED ALL QUESTIONS FULLY AND CORRECTLY.
I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE BY ME ON THIS FORM ARE TRUE, COMPLETE AND CORRECT.

DATE

SIGNATURE

FINAL DETERMINATION ON YOUR ACCESS: The Base Commanding Officer has final authority for determination on granting physical access to
DON controlled installations/facilities under his/her jurisdiction.
BELOW COMPLETED BY BASE REGISTRAR PERSON CONDUCTING IDENTY PROOFING and NCIC CHECK
31. INFORMATION VERIFIED BY:

35. NCIC CHECK PERFORMED BY:

32. ENTERED IN C/S SYSTEM BY:

33. PASS ISSUE DATE:

36. RESULTS OF NCIC CHECK:
NO RECORDS

RECORD IDENTIFIER

RECORD NUMBER:

34. PASS EXPIRATION DATE:

37. RESULTS OF LOCAL RECORDS CHECK:
NO RECORDS

RECORD IDENTIFIER

RECORD NUMBER:

Office of Under Secretary of Defense Directive-Type Memorandum (DTM) 09-012, "Interim Policy Guidance for DoD Physical Access Control,"
December 8, 2009. DTM 09-012 requires that DoD installation government representatives query the National Crime Information Center (NCIC) and
Terrorist Screening Database to vet the claimed identity and to determine the fitness of non-federal government and non-DoD-issued card holders (i.e.
visitors) who are requesting unescorted access to a DoD installation. The minimum criteria to determine the fitness of a visitor is: 1) not on a terrorist
watch list; 2) not on an DoD installation debarment list; and 3) not on a FBI National Criminal Information Center (NCIC) felony wants and warrants list.
Additionally, SECNAV Memo, Policy for Sex Offender Tracking and Assignment and Access Restrictions within the Department of the Navy, of 7 Oct 08
and OPNAVINST 1752.3 established the Navy's policy on sex offenders, requiring Region Commanders (REGCOMs) and Installation Commanding
Officers (COs) to prohibit sex offender access to DoN facilities and Navy owned, leased or PPV housing. This form describes the authority and
purpose to collect and share the required information; and identifies the applicant/visitor and sponsor; and authorizes the DoD to perform the minimum
vetting and fitness determination criteria. A favorable response on the vetting and fitness determination is required to receive access to DOD-controlled
installation/facilities.

SECNAV 5512/1 (MAY 2021)

CUI (when filled in)

Controlled by: DoN
CUI Category: PRVCY
LDC: FEDCON
POC: Rodney Ramseur, [email protected], 202-433-4281

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OMB 0703-0061 05/31/2024

CUI (when filled in)

Instruction for completing the Local Population Access Registration Form
INSTRUCTIONS: Please complete all information in black ink (printed) or by typing. By voluntarily providing your Personal Information, you agree to the following terms
and restrictions:
RESTRICTIONS: Local Population Identification Card/Base Access Pass may only be used by person to whom they are issued and for the specific business/purpose
issued. Applicants are reminded that soliciting (i.e., door-to-door sales) is prohibited on the base, and that such activity is grounds for cancellation of the Pass.
Additionally, such action may result in debarment from the base and legal action. The Base Commanding Officer has discretion over specifying the period of validity
for any Local Population ID Cards/Base Access Passes that are issued under his/her jurisdiction.
Review the Privacy At Statement that is printed at the top of the form
Block 1: Enter the Last Name.
Block 2: Enter the First Name.
Block 3: Enter the Middle Name.
Block 4: If applicable, check the box for Name Suffix.
Block 5: Check the applicable box for Race.
Block 6: Check the applicable box for Gender.
Block 7: Enter Date of Birth.
Block 8: Enter City of Birth.
Block 9: Enter State of Birth.
Block 10: Enter Country of Birth.
Block 11: Check the applicable box for US Citizenship.
Block 12: If not a US Citizen, enter the name of the Country of Citizenship.
Block 13: Two forms of identity source documents from the list of acceptable
documents listed below must be presented to the base registrar with
this completed form. Check the box for the type of Documents that will
be presented for identity proofing. If the document type is not listed, use
the two rows under Other Approved Identity Source Documents to enter
the type of document(s) that you will present.
Block 14: Enter the Document Number located on the Identity Proofing Source
document that was checked in Block 13.
Block 15: Enter the State that issued the Identity Source Document.
Block 16: Enter the Country that issued the Identity Source Document.

Block 17: Enter the Date that the Identity Source Document was issued.
Block 18: Enter the Date that the Identity Source Document will expire.
Block 19: Enter Weight in pounds.
Block 20: Enter Height in inches.
Block 21: Check the applicable box for Hair Color.
Block 22: Check the applicable box for Eye Color.
Block 23: Enter Home Address Including City, State, Zip Code, and Home
Telephone Number.
Block 24: Enter Name of Registrant's Base Sponsor and Base Sponsor's Telephone
Number.
Block 25: Enter Employer Name and address including City, State, Zip Code, and
Employer's Telephone Number.
Block 26: Enter Supervisor's Name including City, State, Zip Code, and
Supervisor's Telephone Number.
Block 27: Check the applicable box for Work Hours box or check the OTHER box
and enter the work hours, then check applicable boxes for Work Days.
Block 28: Check the applicable answer if you have been convicted of
Felony and enter initials.
Block 28: Check the applicable box for felony conviction.
Block 29: Enter initials to accept terms for returning Local Population Identification
Card.
Block 30: Sign and date the form to attest that the foregoing information is true and
complete to best of your knowledge.

LIST OF ACCEPTABLE DOCUMENTS - All documents must not be expired.
Must present one selection from List A or a combination of one selection from List B and one selection
from List C.
List A - Documents that Establish Identity and
Employment Authorization

List B - Documents that Establish Identity
OR

1. U.S. Passport or U.S. Passport Card.
2. Permanent Resident Card or Alien Registration
Receipt Card (Form I-551).
3. Foreign passport that contains a temporary I-551
stamp or temporary I-551 printed notation on a
machine-readable immigrant visa.
4. Employment Authorization Document that
contains a photograph (Form I-766).
5. For a nonimmigrant alien authorized to work for
a specific employer because of his or her status:
a. Foreign Passport; and
b. Form I-94 or Form I-94A that has the
following:
(1) The same name as the passport; and
(2) An endorsement of the alien's
nonimmigrant status as long as that
period of endorsement has not yet
expired and the proposed employment
is not in conflict with and restrictions or
limitations identified on form.
6. Passport from the Federal States of Micronesia
(FSM) or the Republic of the Marshal Islands
(RM) with Form I-94 or Form I-94A indicating
nonimmigrant admission under the Compact
of Free Association Between the United Stated
and FSM or RM.

AND
1. Driver's license or ID card issued by a State or
outlying possession of the United States provided
it contains a photograph or information such as
name, date of birth, gender, height, eye color,
and address.
2. ID card issued by federal, state or local
government agencies or entities, provided it
contains a photograph or information such as
name, date of birth, gender, height, eye color,
and address.
3. School ID card with a photograph
4. Voter's registration card.
5. U.S. Military card or draft record.
6. Military dependent's ID card.
7. U.S. Coast Guard Merchant Mariner Card.
8. Native American tribal document.
9. Driver's license issued by a Canadian
government authority.
For persons under age 18 who are unable to present
a document listed above:

List C - Documents that Establish
Employment Authorization
1. A Social Security Account Number card, unless
the card includes one of the following restrictions:
(1) NOT VALID FOR EMPLOYMEMT
(2) VALID FOR WORK ONY WITH INS
AUTHORIZATION.
(3) VALID FOR WORK ONLY WITH DHS
AUTHORIZATION.
2. Certification of Birth Abroad issued by the
Department of State (Form FS-545).
3. Certification of Birth issued by the Department of
State (Form DS-1360).
4. Original or certified copy of birth certificate issued
by a State, county, municipal authority or territory
of the United States bearing an official seal.
5. Native American tribal document.
6. U.S. Citizen ID Card (Form I-197).
7. Identification Card for Use of Resident Citizen in
the United States (Form I-179).
8. Employment authorization document issued by
the Department of Homeland Security.

10. School record or report card.
11. Clinic, doctor, or hospital record.
12 Day-care or nursery school record.

The remainder of the form will be completed by the Base Registrar Person conducting Identify Proofing process and NCIC check.
AGENCY DISCLOSURE STATEMENT:

The public reporting burden for this collection of information, OMB 0703-0061, is estimated to average ten (10) 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters
Services, Executive Services, at [email protected]. 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 RESPONSE TO THE ABOVE ADDRESS.

Responses should be sent to the Base Registrar.
SECNAV 5512/1 (MAY 2021)

CUI (when filled in)

Controlled by: DoN
CUI Category: PRVCY
LDC: FEDCON
POC: Rodney Ramseur, [email protected], 202-433-4281

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