Ds 1838 Form – Fill Out and Use This PDF

U.S. Department of State

REQUEST FOR PERSONAL IDENTIFICATION CARD

ALL ENTRIES MUST BE TYPED

APPLICANT SECTION (1-20)

1. Applicant's Name (Last, First, Middle, Suffix)

2. Date of Birth (mm-dd-yyyy)

3. Social Security or Employee's Unique ID Number

4. DOS E-mail Address (Required for logical access)

5. Citizenship (If other, specify country)

6. Dual Citizenship (Specify country)

7. Gender

U.S.

Other

Male

Female

8. Applicant Home Address (Street)

9. Apt. No.

10. City

11. State

12. ZIP/Postal Code

13. Employer Name

14. Employer Phone Number

15. Employer Fax Number

16.

Employer Address (Street)

17. Suite No.

18. City

19. State

20. ZIP/Postal Code

REQUESTER SECTION (21-32)

21.

Type of DOS ID Card Requested

22. Escort Authority

DOS Employee (FTE-PSC-WAE)

Vendor

DOS Contractor (Complete items 25a, b)

Press

Yes

No

Foreign

Domestic ]

Other USG Employee (Specify agency)

[

Other (Specify)

Other USG Contractor (Specify agency)

23.

Hours of Access

24. Type of Access (Card):

Normal Business Hours (7:00 AM to 6:30 PM, M-F)

Facility Only

Facility and Logical Access

PIV

Special Business Hours (5:30 AM to 6:30 PM, M-F)

(FAC)

(FLAC)

All domestic facility access cards are programmed providing general access to the

perimeters of HST, SA-1, SA-5, SA-6, SA-15, and SA-42. For further access requirements,

24 Hours/7 Days

None

the employee's Unit Security Officer must e-mail a request to DS_DO_ACS.

25a. Contract Number

25b. Classified Contract

Yes

No

26.

State Department Requester (Last, First, Middle, Suffix)

27. Requester Office Phone Number

28.

Requester Type

29. Requester Office Symbol

EX

HR

DIR

CO

COR

Other

30.

Requester Signature

31. Date (mm-dd-yyyy)

32. Requester's DOS ID Card Number

WHEN COMPLETED, GIVE THIS FORM AND ANY OTHER REQUIRED DOCUMENTATION TO THE APPLICANT. THE APPLICANT MUST HAND CARRY THESE ITEMS ALONG WITH TWO FORMS OF IDENTIFICATION, ONE MUST BE A PHOTO ID, TO THE CREDENTIAL ISSUANCE OFFICE. LOCATED DOMESTICALLY AT HST ROOM B-266 (FOR DOS GOVERNMENT EMPLOYEES), COLUMBIA PLAZA #520 (FOR CONTRACTORS) OR AT REGIONAL LOCATIONS IN NEW YORK CITY, PORTSMOUTH, NH, CHARLESTON, SC AND OVERSEAS AT POST'S CREDENTIAL ISSUANCE OFFICE.

PRIVACY ACT STATEMENT:

Authority: 22 USC 2658; Executive Order 10450; Executive Order 12958; and section 506(A) of the Federal Records Act of 1950, as amended.

Purpose: To conduct appropriate national agency checks prior to issuing a Department of State Personal Identification Card.

Routine Uses: To track, manage, and control access to buildings and restricted areas and to determine the status of individuals entering Department of State premises. In addition to the Department of State, the information may be released to any other Federal, state, or municipal law enforcement agency for law enforcement purposes; agencies having statutory intelligence responsibilities; and agencies having oversight or review authority with regard to investigative responsibilities.

DS-1838	Page 1 of 2
07-2012

INSTRUCTIONS FOR COMPLETING DS-1838 - Page 1

This form must be completed by the U.S. Department of State requester for the applicant. To determine the U.S. Department of State requester for a particular applicant or to resolve any other questions, please see the United States Department of State Personal Identification Card Policy and Procedure document. A copy of this document is available for printing from the Diplomatic Security web site under HSPD-12, instructions for obtaining a DOS Personal ID card.

APPLICANT SECTION (1-20)

INSTRUCTIONS (All entries must be typed, hand written forms will not be accepted)

1.Applicant Name - Enter the applicant's complete legal name.

2.Date of Birth - Enter the applicant's date of birth. Please enter the date in the mm-dd-yyyy format, for example 02-24-2007.

3.Social Security Number - Enter the applicant's Social Security Number OR Employee's Unique ID Number.

4.DOS e-mail address (Required for logical access) - Enter applicant's DOS email address. If a new employee, contact office system administrator.

5.Citizenship - Check the U.S. box if the applicant is a United States citizen. Otherwise check Other and write in the country of citizenship. If the applicant is not a United States citizen or a Reciprocally Cleared Foreign National, s/he will only be issued a Facility Access Card (FAC).

6.Dual Citizenship - For applicants claiming/holding dual citizenship, specify all other countries of citizenship.

7.Gender - Check the box for Male or Female as appropriate.

8.- 12. Applicant Home Address - Enter the applicant's street address (number and street name), apartment or suite number if applicable, city and state of residence and the zip or postal code.

13.Employer Name - Enter the applicant's employer. If the applicant is a DOS Government employee (FTE, PSC, WAE), enter "U.S. Department of State." If the applicant is a contractor, vendor, or caterer enter the company's name and NOT the Government agency that holds the contract.

14.Employer Phone Number - Enter the applicant's employer business telephone number.

15.Employer Fax Number - Enter the applicant's employer business fax number.

16.- 20.Employer Address - Enter the applicant's employer business address (number and street name), suite number if applicable, city and state of business location and the zip or postal code.

REQUESTER SECTION (21-32)

21.Type of DOS Personal Identification Card - Check the box for the type of DOS Personal ID card requested. If the request is for a contractor, ensure line items 25a and b are also completed. If for an employee or contractor of another U.S. Government department or agency, specify the department or agency. If for a member of the press, check whether the news organization is foreign or domestic. If Other, please specify the type of ID card requested.

22.Escort Authority - Indicate whether or not the applicant will be permitted to escort visitors.

23.Hours of Access - Check the appropriate box for the hours of access to Department of State facilities requested normal (7:00am - 6:30pm, M-F), special (5:30am - 6:30pm, M-F), or full time (24/7), or None. Note: Certain overseas posts maintain different work week schedules from the typical M-F.

24.Type of Access - Check the appropriate box for applicant's access to State Department facilities and computer systems. Un-cleared DOS Employee or Contractor = Facility Access Only (FAC). Interim Secret cleared DOS Employee or Contractor = Facility and Logical Access (FLAC) depending on employment position. Fully cleared DOS Employee or Contractor = PIV. Employees or Contractors of other agency, Vendor, Press, or Other = FAC or FLAC as appropriate. All cards will have access to the perimeter of HST, SA-1, -5, -6, -15, and SA-42 except if "NONE" is selected in item #23.

25.Contract Number - Complete this section only if the applicant is a contractor or vendor. Enter contract number and whether the contract is classified.

26.State Department Requester - Type the name of the DOS employee requesting the applicant's DOS Personal ID card. For DOS Government applicants, Bureau EX Office, HR or a delegated Office Director's name is required. For contractors, CO/COR or hiring Bureau EX office is required. Overseas, the post's HR Officer's name is required.

27.Requester Office Phone Number - Enter the telephone number of the DOS employee responsible for requesting the applicant's DOS Personal ID card.

28.Requester Type - Check the box for the type of request for this applicant. If not shown check Other and specify the type.

29.Requester Office Symbol - Enter the requester's office symbol.

30.- 31.Requester Signature/Date - Requester is to sign and date here to authorize the request and certify that all requirements have been completed.

32.Requester's DOS ID Card Number - Requester is to enter their DOS Personal Identification Card or Smart ID Card Number here.

DS-1838	Instruction Page 1 of 2
07-2012