Form Secnav 5512/1 - Department Of The Navy Local Population Id Card/base Access Pass Registration
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3OMB 0703-0061 Exp. 31 Mar 2017
DEPARTMENT OF THE NAVY LOCAL POPULATION ID CARD/BASE ACCESS PASS REGISTRATION
PRIVACY ACT STATEMENT:
AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; OPNAVINST 5530.14E, Navy Physical Security; Marine Corps Order 5530.14A,
Marine Corps Physical Security Program Manual; and E.O. 9397 (SSN), as amended, SORN NM05512-2 .
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.
Sr.
I
II
III
IV
NATIVE HAWAIIAN
6. RACE
5.
HISPANIC OR
AFRICAN AMERICAN
AMERICAN INDIAN OR
NO
YES
WHITE
ASIAN
OR OTHER PACIFIC
LATINO
:
OR BLACK
ALASKIN NATIVE
(Check one):
(Check one or more)
ISLANDER
8. DATE OF BIRTH:
9. CITY OF BIRTH:
10. STATE OF BIRTH:
11. BIRTH COUNTRY:
7.
GENDER
MALE
FEMALE
:
(Check one)
YES
NO
13. DUAL CITIZENSHIP:
12. US CITIZEN (
):
YES
NO
Check
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.
14. IDENTITY SOURCE
16. ISSUED BY
17.
ISSUED BY
18. ISSUED:
19. EXPIRES:
15.
DOCUMENT NUMBER:
DOCUMENTS PRESENTED:
STATE/COURT:
COUNTRY:
United States
Social Security No.
State ID/Drivers License
United States
Passport No.
Certification Number and
Petition Number
Derived - Parent's
United States
Certification Number:
Alien Registration No.
United States
Date of Entry:
Port of Entry:
OTHER APPROVED IDENTITY SOURCE DOCUMENTS:
22. HAIR COLOR
):
23. EYE COLOR (Check one):
20.
21. HEIGHT
(Check one
WEIGHT
:
(Inches)
Blond
Brown
Black
Gray
Red
Brown
Green
Blue
Hazel
:
(Pounds)
White
Silver
Auburn
Bald
Black
Gray
Violet
Unknown
24. HOME ADDRESS
:
HOME PHONE
:
(Include Area Code)
(Include city, state, zip code)
SPONSOR PHONE
:
25. BASE SPONSOR'S NAME:
(Include Area Code)
NAVY LEAGUE OF THE U.S., IMPERIAL VALLEY COUNCIL
EMPLOYMENT ACTIVITY INFORMATON
26. EMPLOYER NAME AND ADDRESS
EMPLOYER PHONE
:
(Include city/state/zip code):
(Include Area Code)
27. SUPERVISOR NAME AND ADDRESS
:
SUPERVISOR PHONE
(Include city/state/zip code)
(Include Area
SECNAV 5512/1 (APR 2014)
FOR OFFICIAL USE ONLY WHEN FILLED - PRIVACY SENSITIVE:
Any misuse or unauthorized disclosure of this information may result in both criminal and civil penalties.
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