Dd Form 2249 Draft - Dod Building Pass Application

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OMB No. 0704-0328
DOD BUILDING PASS APPLICATION
OMB approval expires
(PERMANENT)
The public reporting burden for this collection of information is estimated to average 6 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 this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0704-0328). 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 YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE BUILDING PASS OFFICE
TO WHICH YOU ARE APPLYING.
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301; EO 12356; EO 9397.
PRINCIPAL PURPOSES: To facilitate verification of background investigations for individuals applying for access to DoD buildings in connection
with their official duties.
ROUTINE USES: Information may be furnished to Federal, state, or local agencies for regulatory and law enforcement purposes.
DISCLOSURE: Voluntary; however, refusal to furnish requested information may result in inability to verify essential personal information and
approve requested building pass application.
2a. SOCIAL SECURITY
b. DATE OF BIRTH
1. NAME OF APPLICANT
NUMBER
(YYYYMMDD)
a. LAST
b. FIRST
c. MIDDLE
INITIAL
3. BACKGROUND INVESTIGATION DATA
YEAR
MONTH
YEAR
MONTH
(1)
(2)
(1)
(2)
b. NATIONAL AGENCY CHECK OR
a. BACKGROUND INVESTIGATION
SPECIAL AGENCY CHECK
COMPLETED
COMPLETED
4. EMPLOYMENT CATEGORY (X one)
a. GOVERNMENT
c. CONTRACTOR
(1) ESCORT
e. DOES THE APPLICANT NEED TO
ESCORT OTHERS TO PERFORM
HIS OR HER DUTIES? (X one)
b. FOREIGN
d. PRESS
(2) NO ESCORT
5. BUILDING ACCESS REQUESTED (X one)
a. PENTAGON
c. OTHER (Specify)
(1) 24 HOUR ACCESS
d. ACCESS HOURS
(X one)
b. NCR
(2) BUSINESS HOURS ONLY
(Complete Item 6)
6. JUSTIFICATION FOR NCR ACCESS (List buildings which require 24/7 access.)
D R A F T
7. PASS INFORMATION
a. EXPIRATION DATE OF
b. REASON FOR ISSUANCE (X one)
NEW PASS (YYYYMMDD)
(1) INITIAL ISSUE
(2) RENEWAL
(3) NAME CHANGE
8. AUTHORIZED/REQUESTING OFFICIAL
a. NAME (Last, First, Middle Initial)
b. TELEPHONE NUMBER (Include area code)
c. SIGNATURE
d. DATE SIGNED (YYYYMMDD)
DD FORM 2249, 20081031 DRAFT
PREVIOUS EDITION IS OBSOLETE.
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