> Identification Card / Credential Application

<table style="width:100%;">
<colgroup>
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 8%" />
<col style="width: 17%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="30"><strong>Applicant Data</strong></td>
</tr>
<tr class="even">
<td colspan="21"><strong>Application for</strong> <strong>Identification
Card or</strong> <strong>Credentials</strong></td>
<td colspan="9"><p><strong>ID Card Number:</strong>      </p>
<p>(To be completed by Issuer)</p></td>
</tr>
<tr class="odd">
<td colspan="6">     </td>
<td colspan="6">     </td>
<td colspan="11">     </td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="6">Last Name</td>
<td colspan="6">First Name</td>
<td colspan="11">Middle Name</td>
<td colspan="7">Social Security Number</td>
</tr>
<tr class="odd">
<td colspan="6"><p>     </p>
<p>DOT Administration/Agency</p></td>
<td colspan="6"><p>     </p>
<p>Org. Seg. (OST only)</p>
<p>Line of Business (FAA only)</p></td>
<td colspan="16"><p>     </p>
<p>Date/Place of Birth</p></td>
<td colspan="2"><p> M F</p>
<p>Sex (M/F)</p></td>
</tr>
<tr class="even">
<td>     </td>
<td>ft.</td>
<td>     </td>
<td colspan="3">in.</td>
<td colspan="4">   </td>
<td colspan="2">lbs.</td>
<td colspan="9">     </td>
<td colspan="7" rowspan="2"><p>     </p>
<p>Eye Color</p></td>
<td colspan="2" rowspan="2"><p>     </p>
<p>Citizenship</p></td>
</tr>
<tr class="odd">
<td colspan="6">Height</td>
<td colspan="6">Weight</td>
<td colspan="9">Hair Color</td>
</tr>
<tr class="even">
<td colspan="6">     </td>
<td colspan="6">     </td>
<td colspan="18">     </td>
</tr>
<tr class="odd">
<td colspan="6">Office Routing Symbol</td>
<td colspan="6">Office Phone Number(s)</td>
<td colspan="18">Issuing office use</td>
</tr>
<tr class="even">
<td colspan="12"><p>     </p>
<p>Office e-mail address</p></td>
<td colspan="18"><p>     </p>
<p>Office (Street) Address</p></td>
</tr>
<tr class="odd">
<td colspan="30"><strong>- - - - - - - Contractors Only - - - - - -
-</strong></td>
</tr>
<tr class="even">
<td colspan="9"><p>     </p>
<p>Contractor Company</p></td>
<td colspan="12"><p>     </p>
<p>Contract Number &amp; Expiration Date</p></td>
<td colspan="9"><p>     </p>
<p>Contracting Officer Name and Phone Number (printed)</p></td>
</tr>
<tr class="odd">
<td colspan="30"><strong>- - - - - - - Reason for Issuance- - - - - -
-</strong></td>
</tr>
<tr class="even">
<td colspan="7"> New ID Card or Credential</td>
<td colspan="6"> Lost Damaged</td>
<td colspan="9"> Stolen Expired</td>
<td colspan="5"> Other (Specify):</td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="30"><strong>- - - - - - - Application for Credentials Only-
- - - - - -</strong></td>
</tr>
<tr class="even">
<td colspan="4" rowspan="2">New Credential Request</td>
<td colspan="14" rowspan="2">Type: Executive Official Other</td>
<td colspan="12">     </td>
</tr>
<tr class="odd">
<td colspan="12">Position title to appear on the credential</td>
</tr>
<tr class="even">
<td colspan="30">Credential Justification/Remarks</td>
</tr>
<tr class="odd">
<td colspan="30">          </td>
</tr>
<tr class="even">
<td colspan="30"><strong>- - - - - - - Applicant Signature- - - - - -
-</strong></td>
</tr>
<tr class="odd">
<td colspan="17"> Permanent Contractor Temporary Other:      </td>
<td colspan="12"></td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="17">Employee Type</td>
<td colspan="12">Signature of Applicant</td>
<td>Date of Application</td>
</tr>
<tr class="odd">
<td colspan="30"><strong>- - - - - - - Information below to be filled
out by the Sponsor - - - - - - -</strong></td>
</tr>
<tr class="even">
<td colspan="8">     </td>
<td colspan="6" rowspan="2">Type of Card:</td>
<td colspan="8"> Permanent</td>
<td colspan="2" rowspan="2"><p> Other</p>
<p>(Specify):</p></td>
<td colspan="6" rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="8">Expiration Date of ID Card</td>
<td colspan="8"> Temporary</td>
</tr>
<tr class="even">
<td colspan="14">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="14">Sponsor’s Name &amp; Phone Number (Typed or
Printed)</td>
<td colspan="5">Routing Symbol</td>
<td colspan="4">Date</td>
<td colspan="7">Sponsor’s Signature</td>
</tr>
<tr class="even">
<td colspan="30"><strong>- - - - - - - Identity Verification Information
below to be filled out by the Registrar or Trusted Agent (TA) - - - - -
- -</strong></td>
</tr>
<tr class="odd">
<td colspan="5"> Applicant’s I-9 data has been verified</td>
<td colspan="10"> Applicant has submitted required investigation
paperwork (if required)</td>
<td colspan="11"> Applicant has been fingerprinted</td>
<td colspan="4"> Applicant’s picture for ID has been taken</td>
</tr>
<tr class="even">
<td colspan="9">     </td>
<td colspan="7">     </td>
<td colspan="4">     </td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="9">Registrar’s/ TA’s Name (Typed or Printed)</td>
<td colspan="7">Routing Symbol</td>
<td colspan="4">Date</td>
<td colspan="10">Registrar’s/TA’s Signature</td>
</tr>
<tr class="even">
<td colspan="30"><strong>- - - - - - - Information below to be filled
out by the Registrar - - - - - - -</strong></td>
</tr>
<tr class="odd">
<td colspan="30">Individual is authorized to be issued the following ID
type Permanent Temporary Other:      </td>
</tr>
<tr class="even">
<td colspan="30">Individual has a completed and favorably adjudicated
NAC NACI or higher FBI Fingerprint Check Other:      </td>
</tr>
<tr class="odd">
<td colspan="9">     </td>
<td colspan="7">     </td>
<td colspan="4">     </td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="9">Registrar’s Name (Typed or Printed)</td>
<td colspan="7">Routing Symbol</td>
<td colspan="4">Date</td>
<td colspan="10">Registrar’s Signature</td>
</tr>
<tr class="odd">
<td colspan="30"><strong>- - - - - - - Information below to be filled
out by the Issuer - - - - - - -</strong></td>
</tr>
<tr class="even">
<td colspan="11"> DOT F 1681 is correctly completed.</td>
<td colspan="19"> Applicant’s information in the ID system is
correct.</td>
</tr>
<tr class="odd">
<td colspan="9">     </td>
<td colspan="7">     </td>
<td colspan="4">     </td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="9">Issuer’s Name (Typed or Printed)</td>
<td colspan="7">Routing Symbol</td>
<td colspan="4">Date</td>
<td colspan="10">Issuer’s Signature</td>
</tr>
<tr class="odd">
<td colspan="30"><strong>- - - - - - - Applicant’s Acknowledgement
Receipt - - - - - - -</strong></td>
</tr>
<tr class="even">
<td colspan="30">Your card contains data that may be used to verify your
identity. You must exercise care in handling your card. Do not bend or
twist it, expose it to extreme heat or cold. You may keep the card only
for as long as you are authorized to enter Federal buildings or have
access to Federal information systems. You must return the card when you
no longer need it, or upon demand by the government or your employer.
You must inform your supervisor, your security representative, and/or
the organization that issued your card if it is lost or stolen. You may
be asked to wait for a period of time before a replacement card is
issued. Please acknowledge receipt of your card and that you accept your
responsibilities regarding its use and safeguarding by printing and
signing your name below.</td>
</tr>
<tr class="odd">
<td colspan="25">     </td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="25">Applicant’s Name (Typed or Printed)</td>
<td colspan="5">Date</td>
</tr>
<tr class="odd">
<td colspan="30"><strong>DOT F 1681 (test – 10/27/05)</strong></td>
</tr>
</tbody>
</table>

**Privacy Act Notice:**

The information on this form is requested under authority of Titles 5
and 49, USC; Title 32, CFR; and Title 40 USC 486c. Submission of all
data is mandatory in order to receive DOT identification media. The
purpose is to provide a ready concentration of employee personal data to
facilitate issuance, accountability, and recovery of required
identification/credential card(s) which are issued to
employees/contractors. The information provided will be used to issue
such identification/credential card(s) as may be required to enable the
employee or contractor to properly conduct assigned duties. Failure to
provide all or any part of the requested data will result in your
inability to be properly identified and, therefore, be unable to
properly perform all aspects of your assigned official duties.