Badge Applications

0. Contact Email

example@example.com

1. Last Name

2. First Name

3. Middle Name

4. Name Suffix

5. Hispanic or Latino

6. Race

7. Gender

8. Date of Birth

Date

9. City of Birth

Street Address

Street Address Line 2

City

10. State of Birth

Street Address

Street Address Line 2

State

11. Birth Country

Street Address

Street Address Line 2

Country

12. US Citizen

13. Dual Citizenship

Other

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 Documents Presented

14a. Social Security Number

If providing a DL# or Passport # you must also provide your SSN

14b. State ID/Drivers License

Rows	15b. Document Number	16b. Issued by State/Court	18b. Issued	19b. Expires
State ID/Drivers License

14c. Passport No.

Rows	15c. Document Number	16c. Issued by State/Court	17c. Issued by Country	18c. Issued	19c. Expires
Passport No.

14d. Certification Number and Petition Number

Rows	15d. Document Number	16d. Issued by State/Court	17d. Issued by Country	18d. Issued	19d. Expires
Certification Number and Petition Number

14e. Derived - Parent's Certification Number

Rows	15e. Document Number	16e. Issued by State/Court	17e. Issued by Country	18e. Issued	19e. Expires
Derived - Parent's Certification Number:

14f. Alien Registration Number

Rows	15f. Document Number	16f. Issued by State/Court	17f. Issued by Country	18f. Issued	19f. Expires	Date of Entry	Port of Entry
Alien Registration Number

14g. Other Approved Identity Source Document Presented

Rows	14g. Document Name	15g. Document Number	16g. Issued by State/Court	17g. Issued by Country	18g. Issued	19g. Expires
Other

20. Weight

Pounds

21. Height

Inches

22. Hair Color

23. Eye Color

24. Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone

Format: (000) 000-0000.

25. Base Sponsor

Sponsor Phone

Area CodePhone Number

26. Employer Name and Address

Employer Phone

Area CodePhone Number

27. Supervisor Name and Address

Supervisor Phone

Area CodePhone Number

Download Page 2 Here

You must print, hand sign, and scan/photograph the signed document for upload.

Upload Page 2

Browse Files

Acceptable file types: JPG, PNG, TIFF, BMP, PSD, PDF

DEPARTMENT OF THE NAVY LOCAL POPULATION ID CARD/BASE ACCESS PASS REGISTRATION

Download Page 2 Here