New Badge Request
Social Security Number (if available)
Today's Date
MM
/
DD
/
YYYY
Submitted By:
Affiliation *
Task No.
First Name *
Middle Name or Initial or NMI (No Middle Initial)
Last Name *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Country of Birth *
City of Birth *
Country of Citizenship *
Permanent Street Address *
Permanent City *
Permanent State *
Permanent Zip Code *
Personal Email Address *
Personal Phone Number *
Current US Address (if different from Permanent)
Host *
Planned beginning date of visit *
MM
/
DD
/
YYYY
Planned ending date of visit
MM
/
DD
/
YYYY
Has applicant lived and worked in the U.S. continuously for at least 3 years?
Clear selection
Title or Position *
Work E-Mail Address (if known)
Planned Building No.
Planned Room No.
Business Phone Number
NASA Computer Access Needed? *
NASA E-Mail Needed? *
Work Description (include the programs/projects the applicant will support and the tasks/technologies they will use): *
Will they need “after-hours” access? *
If so, when and to where, specifically, and for how long? Provide justification.
If new badge recipient is in the US: They will receive a link where they can upload their identity documents. Please do not email due to security issues. If not in the US: They will be contacted for the best way to forward documents.
Foreign National Information
Dual Citizenship Country (if applicable)
Naturalization Number
Nationalization Place
Naturalization Date
MM
/
DD
/
YYYY
U.S. Visa Information
Visa Type:
Clear selection
Is this a Visa Waiver?
Clear selection
Visa Number
Visa Expiration Date
MM
/
DD
/
YYYY
Passport Country of Issue
Passport Number
Passport Expiration Date
MM
/
DD
/
YYYY
Is he/she a Permanent Resident Alien (Green Card Holder)
Clear selection
If Yes, Number
Expiration Date
MM
/
DD
/
YYYY
Date Issued
MM
/
DD
/
YYYY
Place of Entry into U.S. (Recent Entry)
Date of Entry into U.S. (Recent Entry)
MM
/
DD
/
YYYY
Export controlled items involved in the programs/projects (i.e. technologies, hardware, software)
For office use only:
Date submitted to IdMAX
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of UMBC. Report Abuse