Badge Applications

0. Contact Email

example@example.com

1. Last Name*

2. First Name*

3. Middle Name

4. Name Suffix

5. Hispanic or Latino*

YesNo

6. Race*

7. Gender*

MaleFemale

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*

YesNo

13. Dual Citizenship*

NoOther

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*

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

14c. Passport No.*

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

14d. Certification Number and Petition Number*

	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*

	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*

	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*

	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*

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