HHS-745 (5/07) Page 1
PSC Graphics (301) 443-1090 EF
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Department of Health and Human Services (HHS)
Identifi cation (ID) Badge Request
(Other Federal Departments may call this type of ID badge a
Personal Identity Verifi cation [PIV] card)
HHS ID BADGE ISSUING FACILITY
IDENTIFICATION NUMBER
Privacy Act Statement: The information on this form is collected by the Department of Health and Human Services (HHS) to is-
sue you an identifi cation badge called the HHS ID Badge. The purpose of the ID Badge is to help ensure the safety and security of
government buildings, the people who work in them, and government computer systems. When you use your ID Badge an ID Badge
system will verify that you are authorized to use government facilities. The system also will track and control the ID Badges that are
issued. The authority to collect this information is 5 U.S.C. § 301; Presidential Memorandum on Upgrading Security at Federal Facili-
ties, June 28, 1995; and Homeland Security Presidential Directive 12, August 27, 2004. The authority to request your Social Security
number is Executive Order 9397. The disclosure of your Social Security number is voluntary, but it will assist in verifying your identity
to process this application. The information on this form may be disclosed only with your written consent, except where permitted by
the Privacy Act. The disclosures permitted by the Privacy Act include disclosure to: the Department of Justice, a court, or other gov-
ernment offi cials when the records are relevant and necessary to a law suit; the appropriate public authority (Federal, foreign, State,
local, tribal, or otherwise) to enforce, investigate, or prosecute, when a record indicates a violation of law or regulation; a Member
of Congress or congressional staff member at your written request; the National Archives and Records Administration for records
management inspections; authorized Federal contractors, grantees, or volunteers who need access to the records to do agency
work and who have agreed to comply with the Privacy Act; any source that has records an agency needs to decide whether to retain
an employee, continue a security clearance, or agree to a contract, grant, license or benefi t; Federal, State, or local agencies, enti-
ties, individuals, or foreign governments to enable an intelligence agency to carry out its responsibilities; the Offi ce of Management
and Budget to evaluate private relief legislation; and to other Federal agencies to notify them when your ID Badge is no longer valid.
If you do not provide all of the requested information, we may deny you an ID Badge. Without an ID Badge, you will not have access
to certain Federal facilities or systems. If using an ID Badge is a condition of your employment, not providing the information may
prevent you from being able to work.
A. Applicant Information (To be completed by Applicant, Sponsor, or Authorized Offi cial)
1. REASON FOR ISSUANCE
New Application Renewal Lost Stolen Damaged Expired
Other (specify) :
2. NAME (Last, First, Middle) OTHER NAME(S) USED
3. DATE OF BIRTH (mm/dd/yyyy) 4. PLACE OF BIRTH
5. SOCIAL SECURITY NUMBER (xxx-xx-xxxx)
City State or Province Country
6. U.S. CITIZEN
Yes No (specify citizenship) :
7. POSITION TITLE 8. AGENCY / DIVISION
9. BUILDING / OFFICE ADDRESS 10. WORK PHONE
11. EMAIL
For Contractors, complete lines 12 through 14
12. ORGANIZATION / COMPANY NAME
13. ADDRESS OF ORGANIZATION / COMPANY
14. TELEPHONE OF ORGANIZATION / COMPANY
To be completed by Applicant
15. APPLICANT SIGNATURE 16. DATE (mm/dd/yyyy)
I hereby authorize the release of information in this application to appropriate Federal agencies for the purposes of process-
ing this application and verifying my identity. I also acknowledge that if I provide or assist in the provision of false informa-
tion or non-verifi able information, and/or I purposely omit information, it could result in loss of access to HHS facilities and
IT systems and in disciplinary action including removal from Federal service or a Federal contract, and I may be subject to
prosecution under applicable Federal criminal and civil statutes.
