**Instructions for Personal Identity Verification Credential Request
form**

All information must be legibly printed in blue or black ink.

Forms with strikethroughs or white-out will not be accepted.

All signatures must be original signatures, no copies or stamped
signatures.

Sponsors / Registrars / Issuers should maintain a log of all applicant
forms they sign (Name, badge type, and date). When the information is
entered into the electronic PIV system you maybe asked to digitally sign
the forms of applicants that you have processed through the manual
(paper-based) process.

Once the Sponsor signs the form, the form should never be given to the
applicant except to fill in applicant information in the presence of the
Registrar or Issuer.

**[Sponsor]{.underline}**

Complete lines 1 -- 10 about the applicant, lines 11 -- 13 about
yourself, and sign and date line 14. Send the form to your designated
Registrar's office.

[Line 2 Legal Name of Applicant:]{.underline} - Last, First Middle names
-- as they appear on official documents (identity proofing source
documents)

[Line 3 Affiliation:]{.underline}

**Employee** -- Permanent DOI employee

> **Temporary Employee** -- Temporary employee/intern paid or obtaining
> some type of benefit directly from DOI

**Contractor** -- an individual working, under contract, for DOI

**Retiree** -- Retired DOI employee

**Volunteer** -- a non-paid individual working under the supervision of
DOI

[Line 4 Citizenship]{.underline}: If applicant is not a U.S. citizen
please note the country of citizenship and verify that the applicant has
been a resident of the United States for at least the last 3 years. If
the applicant has not been a resident of the U.S. for at least 3 years,
they may not qualify for a PIV card due to restrictions associated with
the background investigation. Please contact your Bureau Personnel
Security Specialist for further information. Also note, the expiration
of their ID cannot extend past the expiration date of their INS
documents (i.e., work permit, visa, etc.).

[Line 5 Employee Title]{.underline} -- Only for permanent employees of
DOI

> **United States Government** -- used for employees without a specific
> title listed below and temporary employees, contractors, retirees, and
> volunteers. This is the default title for the area above the photo on
> the PIV cards.
>
> **LE (Law Enforcement)** -- DOI employees who are sworn Law
> Enforcement Officers

**Firefighter** -- Individuals who are employed by DOI in a firefighter
capacity.

**Security** -- DOI employee in 080 job series

**Investigator** -- DOI employee in 1801 and 1810 job series

[Line 6 Federal Emergency Response Official]{.underline} - Must be
approved by Bureau/Office Law Enforcement Director -- submit Form XXX

[Line 7 Bureau:]{.underline} - bureau name that will appear on the
applicant's card

Bureau of Land Management Bureau of Indian Affairs

Bureau of Reclamation Minerals Management Service

National Business Center National Indian Gaming Commission

National Parks Service U.S. Fish and Wildlife Service

United States Geological Survey Office of Surface Mining

Office of the Inspector General Office of the Secretary

Office of the Solicitor

[Lines 8 & 9 -- Work address:]{.underline} -- Duty station location

[Line 10 Contractor Company / Contract Number]{.underline} -- for
contractors only

**[Registrar]{.underline}**

When applicant arrives in your office, have the applicant complete lines
15 -- 19 and sign and date line 20. Verify identity source documents
(see attached list of acceptable documents), record the document
information, and attach a copy of the documents to the request form. One
of the documents must be a State or Federal issued photo ID.

If the applicant is not a U.S. citizen, verify that "No" has been
checked on Line 4 and ensure that the applicant has been a resident of
the U.S. for at least the past 3 years. If the applicant's INS
documentation expires in less than 5 years from the application date,
circle the expiration date of the document in red. The PIV card cannot
be issued with an expiration date that is later than the date the
applicant is legally allowed to reside and work in the U.S.

When the NAC (FBI Fingerprint check) has been completed and successfully
adjudicated, the Registrar must fill in lines 36 -- 38 and sign and date
line 39.

Ensure that the applicant's photo has been sent to the designated
Issuer.

[Line 16 Applicant Physical Characteristics:]{.underline}

**Hair color**: Auburn, Bald, Black, Blond, Brown, Gray, Red, White,

**Eye Color**: Black, Blue, Brown, Green, Gray, Hazel

**Height** -- Feet and Inches

**Weight** - in pounds

[Lines 21- 28 Identity Source Documents:]{.underline} - List of
acceptable documents is on the last page of these instructions. Copies
of both identity source documents must be attached to the PIV request
form.

One of the documents must be a State or Federal issued photo ID

Lines 21 & 25 - Name of the applicant as it appears on the document

Lines 23 & 27 -- Name of department or agency that issued the document

[Line 29 Picture taken]{.underline}: -- photo must be sent to Issuer
(Polaroid for DI-238A/ DI-238 and digital for others). Registrar must
also digitally store picture for later use in smartcard issuance.

[Line 30 Fingerprints taken or received:]{.underline} Fingerprints can
either be done digitally or on the paper cards. Ensure the correct
fingerprint card was used; Employees use SF-87 and Contractors use
FD-258.

[Line 31 Background Investigation Application Forms
Complete:]{.underline} Background Investigation (BI) forms are required
for new applicants. If the applicant is a current DOI employee or
affiliate, verify that as least a NACI has been completed and is on
file. If there is not any record of a NACI for the applicant, they must
complete the BI forms. BI forms include SF-85, SF-85P with Credit Report
Release, or SF-86 and OF-306. The minimum investigation for the issuance
of a PIV credential is a National Agency Check with Inquiries (NACI) and
the NAC portion must be completed prior to the issuance of the card. For
a NACI an employee needs to complete the SF-85 and a contractor or other
affiliate must complete an SF-85P. To receive an advanced NAC
(Fingerprint check results) you must make sure that code #3 is placed in
block B "Extra Coverage" of the SF-85, SF-85P, or SF-86.

[Lines 32 -- 35 NAC Adjudication Results:]{.underline} Adjudication of
the NAC, which includes the OPM Security/Suitability Investigations
Index (SII), the Defense Clearance and Investigations Index (DCII) and
the FBI National Criminal History Fingerprint Check, must be complete
before the PIV card can be issued. If the results are not received
within 5 days, the PIV credential may be issued based upon the results
of the FBI National Criminal History Fingerprint Check (OMB memo
M05-24).

**[Issuer]{.underline}**

The issuer is responsible for issuing the PIV credential, only after
Sections A, B, & C are complete and signed. The Issuer must verify the
identity of the applicant by comparing the ID to the attached source
documents and the source document presented by the applicant at the time
of issuance. The Issuer then completes lines 43 -- 45 and signs and
dates line 46. The Issuer must then have the applicant sign for the
receipt of the PIV credential.

[Lines 40 -- 42 PIV credential information:]{.underline} - Fill in the
name on the credential, the credential serial number, and the expiration
date printed on the credential. Verify that the expiration date is not
greater than 5 years from the issuance date and that the expiration date
does not exceed the expiration date of the INS documents for non-U.S.
citizens.

**LIST OF ACCEPTABLE DOCUMENTS**

+-----------------------+-----------------------+-----------------------+
| **List A**            | **List B**            | **List C**            |
+-----------------------+-----------------------+-----------------------+
| U. S. Passport        | Driver's license or   | U.S. social security  |
| (unexpired or         | ID card issued by a   | card issued by the    |
| expired)              | state or outlying     | Social Security       |
|                       | possession of the     | Administration (other |
|                       | United States         | than a card stating   |
|                       | provided it contains  | it is not valid for   |
|                       | a photograph or       | employment)           |
|                       | information such as   |                       |
|                       | name, date of birth,  |                       |
|                       | gender, height, eye   |                       |
|                       | color and address     |                       |
+-----------------------+-----------------------+-----------------------+
| Certificate of U.S.   | ID card issued by     | Certification of      |
| Citizenship (Form     | Federal, State or     | Birth abroad issued   |
| N-560 or N-561)       | local government      | by the Department of  |
|                       | agencies of entities, | State (form FS-545 or |
|                       | provided it contains  | Form DS-1350)         |
|                       | a photograph or       |                       |
|                       | information such as   |                       |
|                       | name, date of birth,  |                       |
|                       | gender, height, eye   |                       |
|                       | color and address     |                       |
+-----------------------+-----------------------+-----------------------+
| Certificate of        | School ID card with a | Original or certified |
| Naturalization (Form  | photograph            | copy of a birth       |
| N-550 or N-570)       |                       | certificate issued by |
|                       |                       | a state, county,      |
|                       |                       | municipal authority   |
|                       |                       | or outlying           |
|                       |                       | possession of the     |
|                       |                       | United States bearing |
|                       |                       | an official seal.     |
+-----------------------+-----------------------+-----------------------+
| Unexpired foreign     | Voter's registration  | Native American       |
| passport, with I-551  | card                  | tribal document       |
| stamp or attached     |                       |                       |
| Form I-94 indicating  |                       |                       |
| unexpired employment  |                       |                       |
| authorization         |                       |                       |
+-----------------------+-----------------------+-----------------------+
| Permanent Resident    | U.S. Military card or | U.S. Citizen ID Card  |
| Card or Alien         | draft record          |                       |
| Registration Receipt  |                       | (Form I-197)          |
| Card with photograph  |                       |                       |
| (Form I-151 or I-551) |                       |                       |
+-----------------------+-----------------------+-----------------------+
| Unexpired Temporary   | Military dependent's  | ID Card for use of    |
| Resident Card (Form   | ID card               | Resident Citizen in   |
| I-688)                |                       | the United States     |
|                       |                       | (Form I-179)          |
+-----------------------+-----------------------+-----------------------+
| Unexpired Employment  | U.S. Coast Guard      | Unexpired employment  |
| Authorization Card    | Merchant Mariner Card | authorization         |
| (Form I-688A)         |                       | document issued by    |
|                       |                       | DHS (other than those |
|                       |                       | listed under List A)  |
+-----------------------+-----------------------+-----------------------+
| Unexpired Reentry     | Driver's license      |                       |
| Permit (Form I-327)   | issued by a Canadian  |                       |
|                       | government authority  |                       |
+-----------------------+-----------------------+-----------------------+
| Unexpired Refugee     | **For persons under   |                       |
| Travel Document (form | age 18 who are unable |                       |
| I-571)                | to present a document |                       |
|                       | listed above**:       |                       |
+-----------------------+-----------------------+-----------------------+
|                       | School record or      |                       |
|                       | report card           |                       |
+-----------------------+-----------------------+-----------------------+
|                       | Clinic, doctor or     |                       |
|                       | hospital record       |                       |
+-----------------------+-----------------------+-----------------------+
|                       | Day-care or nursery   |                       |
|                       | school record         |                       |
+-----------------------+-----------------------+-----------------------+