Form Cd-591 - Department Of Commerce Personal Identity Verification (Piv) Request

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FORM CD-591
U.S. DEPARTMENT OF COMMERCE
10/05
Department of Commerce Personal Identity Verification (PIV) Request
A. PIV Request & Source Document Confirmation (To be completed by Sponsor)
1. Replacement card?
No
Yes
1a. Reason for Replacement
2. Background investigation completed:
No
Yes
Type/Date Completed
(If Yes, skip to Line 4 below)
3. Background investigation package complete?
Yes (Required for new cards only)
Applicant Information
4. Type:
Employee
Contractor
Affiliate/Guest/Other
5. Name (Last, First, Middle)
Sponsor Information
Sponsor Information
6. Applicant ID Number (from Training Certificate)
11. Sponsor ID Number
7. Position or Title
11. Sponsor ID Number
12. Name
8. Organization
12. Name
9. Work Phone
10. Email
I agree to sponsor the above Applicant for a PIV card and certify that the information is accurate to the best of my knowledge.
13. Sponsor Signature
14. Date (mm/dd/yyyy) ____/____/________
B. Identity-Proofing (To be completed by Sponsor, Enrollment Official, or Registrar)
Enrollment Official Information (If Applicable)
15. I-9 Form Attached?
Yes
Identity Proofer Information (If Applicable)
16. Copies of ID Source documents attached?
Yes
18. Enrollment Official ID Number
18. Identity Proofer ID Number
17. Did Applicant present two forms of identification, one of which was a photo ID
19. Name
19. Name
issued by a state or the Federal government?
Yes
I certify that the above Applicant appeared before me and presented two ID source documents, which appeared to be genuine.
20. ID Proofer Signature
21. Date (mm/dd/yyyy) ____/____/________
Signed by Sponsor / Enrollment Official (circle one)
C. Card Approval (To be completed by Registrar, after Sections A & B are completed)
Based on NAC / NACI / FBI Fingerprint Check Results (Circle one)
Registrar Information
Registrar Information
22. Date Completed (mm/dd/yyyy) _____/_____/__________
25. Register ID Number
23. Favorable?
Yes
No (If no, notify Sponsor for adjudication decision)
25. Registrar ID Number
26. Name
24. Comments
26. Name
I hereby
Approve
Disapprove issuance of a PIV card to the above-named Applicant.
27. Registrar Signature
28. Date (mm/dd/yyyy) ____/____/________
D. Card Details (To be completed by Final Issuer after Section C has been completed)
Issueration
Issuer Information
29. Name on Card
32. Issuer ID Number
30. Agency PIV Card Number
32. Issuer ID Number
33. Name
31. Card Expiration Date (mm/dd/yyyy) _____/_____/__________
33. Name
I acknowledge issuance of a PIV card to the Applicant identified above based on verification of the Applicant’s identity and
the above Registrar’s issuance approval.
34. Issuer Signature
35. Date (mm/dd/yyyy) ____/____/________
E. Applicant Acknowledgement (To be completed by Applicant, after Section D is completed)
I, the Applicant, confirm receipt of the PIV 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 this card.
36. Applicant Signature
38. Date (mm/dd/yyyy) ____/____/________
Upon completion, return this form to the Registrar

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