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

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

All strikethroughs must be initialed.

Forms with 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 (career/ career conditional) DOI employee

> **Temporary Employee** -- Temporary, Term, Student (SCEP, STEP), or
> intern paid or obtaining some type of benefit directly from DOI

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

**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 (4b), work permit number (or
other INS documentation indicating eligibility to work) and expiration
date (4c), 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

[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 Park 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}**

**[Field 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.

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.

Complete lines 32 & 33 and sign & date line 34. Forward this document to
the Human Resources / Security Management Office to have background
check completed and/or verified.

[Line 15 Birth Date and Social Security Number:]{.underline} SSN is
needed by the Personnel Security Specialist to verify background
investigation information with OPM.

[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 and Temporary employees use SF-87
and Contractors and Volunteers use FD-258.

[Line 31 Background Investigation Application Forms
Complete:]{.underline} Background Investigation (BI) forms are required
for applicants for whom an appropriate BI cannot be verified. 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. Place a "R" in the code block
in the area marked for 'OPM use only' to receive the fingerprint check
results as soon as they are completed (prior to the NAC).

**[Human Resources / Security Management Office:]{.underline}** After
the background investigation has been successfully completed, fill in
lines 35 - 37 and sign & date line 38. The form should then be forwarded
to the Registrar for final approval.

[Lines 35 -- 37 NAC Adjudication Results:]{.underline} Any applicant
receiving a PIV card must have at least a NACI done. The PIV card may be
issued after the NAC portion of the NACI is completed. 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).

Note on the form which portion of the NACI was completed (fingerprint,
NAC, NACI). If the applicant has a higher level background investigation
on record with OPM, mark that the NACI (minimum requirement) was
completed and note the type of investigation on the comments line.

**[Registrar:]{.underline}** Review the PIV form for completeness and
accuracy, ensure that copies of the identity source documents are
attached to the form, fill in lines 39 -- 41, and sign & date line 42.
Forward the PIV form and copies of the identity documents to the
designated issuer and notify the applicant to report to the designated
issuer. If necessary, ensure that the applicant's photo has been sent to
the designated Issuer.

**[Issuer]{.underline}**

The issuer is responsible for issuing the PIV credential, only after
Sections A and B 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 40 -- 48 and signs & dates
line 49. The Issuer must then have the applicant sign for the receipt of
the PIV credential on line 50.

[Lines 43 -- 45 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         |                       |
+-----------------------+-----------------------+-----------------------+