Form NCIS5512/1 "Request for Ncis Credentials"

Form 5512/1 is a U.S. Department of the Navy - Naval Criminal Investigative Service form also known as the "Request For Ncis Credentials". The latest edition of the form was released in February 1, 2014 and is available for digital filing.

Download an up-to-date fillable Form 5512/1 in PDF-format down below or look it up on the U.S. Department of the Navy - Naval Criminal Investigative Service Forms website.

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Download Form NCIS5512/1 "Request for Ncis Credentials"

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REQUEST FOR NCIS CREDENTIALS
AUTHORITY: Privacy Act of 1974, Executive Order 9397, and SECNAVINST 5211.5E, authorizes the collection of this information.
PRINCIPAL PURPOSE(S): Principle Purpose(s): Obtain information necessary to make a determination of eligibility for NCIS credentials and badges.
ROUTINE USE(S): The information provided will not be divulged without your written authorization to any one other than those duly authorized to collect,
process, report, analyze, or evaluate the results of the examination or inquiry. This document is property of the Naval Criminal Investigative Service and may
contain information that is Privacy Act Sensitive to be used for official purposes only.
DISCLOSURE: You are not required to provide this information, however, failure to do so or any misrepresentation (by answers) may serve as a basis
for denial of NCIS credentials.
FROM:
REQUEST DATE:
RCVD DATE:
(Office Code )
(Code 11A)
(dd-mmm-yyyy)
(dd-mmm-yyyy)
TO: Deputy Assistant Director, Security & Facilities Department (Code 11A)
NAME:
First
M.I.
DoD EDI PN:
Last
STATUS:
GS-1811
Other Civilian (Specify)
USMC Special Agent (Rank)
Other Military (Rank/Specify)
TITLE REQUESTED:
a.
Special Agent
c.
Operational Representative
e.
Retired Credentials
b.
Investigator
w/Badge
f.
DoD Law Enforcement Officer ID
w/ Firearms
w/Firearms
(Policy Agreement attached)
d.
Administrative Representative
g.
Shadow Box
(Non-agent personnel must attach justification if requesting credentials w/firearms or Op Rep badge)
PREVIOUS CREDENTIALS ISSUED:
No
Yes
Number:
Issue Date:
(
dd-mmm-yyyy)
Bearer’s Signature
SAC/DAD Printed Name
SAC/DAD Signature
(This section to be completed by Code 11A)
FIRST ENDORSEMENT (Issuance of credentials, badges, & protective service pins)
Date:
(dd-mmm-yyyy)
Enclosures: Credential Card No.:
Badge No. 1:
Badge No. 2:
ID Card No.:
Protective Service Pin No.:
By direction (printed name)
(Signature)
EMPLOYEE CERTIFICATION
(This section to be completed by credentials holder upon receipt of credentials. Return completed form to Code 11A.)
I hereby acknowledge receipt of the permanent credentials, as indicated by the first endorsement noted above. I certify that I
am cognizant of the provisions of NCIS-1 Chapter 30, Credentials, Badges and Protective Service Pins (effective edition), as it
pertains to the issuance, control, use of, loss of, and disciplinary action concerning same.
SIGNATURE OF BEARER: ___________________________________
DATE:
(dd-mmm-yyyy)
NCIS 5512/1 (2-2014)
- FOR OFFICIAL USE ONLY -
Previous Editions Obsolete 1 of 2
REQUEST FOR NCIS CREDENTIALS
AUTHORITY: Privacy Act of 1974, Executive Order 9397, and SECNAVINST 5211.5E, authorizes the collection of this information.
PRINCIPAL PURPOSE(S): Principle Purpose(s): Obtain information necessary to make a determination of eligibility for NCIS credentials and badges.
ROUTINE USE(S): The information provided will not be divulged without your written authorization to any one other than those duly authorized to collect,
process, report, analyze, or evaluate the results of the examination or inquiry. This document is property of the Naval Criminal Investigative Service and may
contain information that is Privacy Act Sensitive to be used for official purposes only.
DISCLOSURE: You are not required to provide this information, however, failure to do so or any misrepresentation (by answers) may serve as a basis
for denial of NCIS credentials.
FROM:
REQUEST DATE:
RCVD DATE:
(Office Code )
(Code 11A)
(dd-mmm-yyyy)
(dd-mmm-yyyy)
TO: Deputy Assistant Director, Security & Facilities Department (Code 11A)
NAME:
First
M.I.
DoD EDI PN:
Last
STATUS:
GS-1811
Other Civilian (Specify)
USMC Special Agent (Rank)
Other Military (Rank/Specify)
TITLE REQUESTED:
a.
Special Agent
c.
Operational Representative
e.
Retired Credentials
b.
Investigator
w/Badge
f.
DoD Law Enforcement Officer ID
w/ Firearms
w/Firearms
(Policy Agreement attached)
d.
Administrative Representative
g.
Shadow Box
(Non-agent personnel must attach justification if requesting credentials w/firearms or Op Rep badge)
PREVIOUS CREDENTIALS ISSUED:
No
Yes
Number:
Issue Date:
(
dd-mmm-yyyy)
Bearer’s Signature
SAC/DAD Printed Name
SAC/DAD Signature
(This section to be completed by Code 11A)
FIRST ENDORSEMENT (Issuance of credentials, badges, & protective service pins)
Date:
(dd-mmm-yyyy)
Enclosures: Credential Card No.:
Badge No. 1:
Badge No. 2:
ID Card No.:
Protective Service Pin No.:
By direction (printed name)
(Signature)
EMPLOYEE CERTIFICATION
(This section to be completed by credentials holder upon receipt of credentials. Return completed form to Code 11A.)
I hereby acknowledge receipt of the permanent credentials, as indicated by the first endorsement noted above. I certify that I
am cognizant of the provisions of NCIS-1 Chapter 30, Credentials, Badges and Protective Service Pins (effective edition), as it
pertains to the issuance, control, use of, loss of, and disciplinary action concerning same.
SIGNATURE OF BEARER: ___________________________________
DATE:
(dd-mmm-yyyy)
NCIS 5512/1 (2-2014)
- FOR OFFICIAL USE ONLY -
Previous Editions Obsolete 1 of 2
REQUEST FOR NCIS CREDENTIALS
Signature Card for Credentials
Printed Name: __________________________________________
- Sign in the box below – DO NOT EXTEND OUTSIDE THE BOX
- Use black medium ink only
-
Return to: NCISHQ, ATTN: Code 11A
Signature Card for Credentials
Printed Name: __________________________________________
- Sign in the box below – DO NOT EXTEND OUTSIDE THE BOX
- Use black medium ink only
- Return to: NCISHQ, ATTN: Code 11A
NCIS 5512/1 (2-2014)
- FOR OFFICIAL USE ONLY -
Previous Editions Obsolete 2 of 2
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