117th VISITOR REQUEST.pdf
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- Construct Blast Fence
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- W50S6M-25-B-A011
About this file
This document is a 117 SFS Badge/Visitor Request form subject to the Privacy Act of 1974, designed to collect detailed personal and access information for individuals seeking entry to 117 ARW property. The form captures comprehensive visitor details including personal identification, contact information, citizenship status, and specific access requirements. The document is intended to support DoD physical security and information assurance programs by verifying individual identity and tracking facility access, with sections for long-term (31+ days) or short-term (30 days or less) access for various personnel types such as government employees, contractors, visitors, volunteers, students, and caretakers. The specific request on this form is for a "Security Project" with access dates from 11/01/2024 to 10/31/2025, sponsored by Mr. William Hall from the 117 CES/117 MSC unit, with access requested during standard business hours (0700-1700).
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Text version
117 SFS BADGE/ VISITOR REQUEST
(Subject to the Privacy Act of 1974)
PRIVACY ACT STATEMENT
AUTHORITY: E.O. 9379; The Privacy Act of 1974, 5 U.S.C. 522a; DODD 8500.1
PRINCIPAL PURPOSE(S): To provide necessary information to determine if applicant meets installation access control requirements IAW HSPD12, DoD 5200.8, DTM 09-12, FIPS201, AND AFI 31-113. Use of SSN is necessary to make positive identification of an applicant. Records in the Defense Biometric Identification System (DBIDS) are maintained to support DoD physical security and information assurance programs and are used for identity verification purposes, to record personal property registered with the DoD, and for producing facility management reports. SSN, Drivers License Number, or other acceptable identification will be used to distinguish individuals who request access to 117 ARW property.
DISCLOSURE: Voluntary. However, failure to provide the requested information may result in denial of an access credential and denial of access to 117 ARW property.
REQUIRES ACCES TO
117 ARW
LONG TERM (31 days or more)
SHORT TERM (30 days or less)
TYPE:
GOV Employee
GOV Contractor
Visitor
Volunteer
Student
Caretaker
I. VISITOR’S INFORMATION
NAME (Last, First Middle)
BIRTH (MM/ DD/ YYYY)
SOCIAL SECURITY NUMBER
ETHNICITY
DRIVER’S LICENSE NUMBER
STATE
COMPANY/ UNIT
HOME ADDRESS
TELEPHONE NUMBER EMAIL ADDRESS
US CITIZEN? ALIEN/ PASSPORT NUMBER/ COUNTRY OF
BIRTH (Non-US Citizen)
GENDER HEIGHT (ft/in) WEIGHT (lbs) EYE COLOR HAIR COLOR
YES
NO
Does Applicant have a valid Federally Issued Common Access Card (CAC) or TWIC? YES □ NO □
II. ORGANIZATION/ SPONSOR AND ACCESS DATES/TIMES
START DATE (MM/DD/YYYY)
DAY/ TIME REQUESTING ACCESS
Hours (e.g.
0700- 1700)
MON TUES WED THUR FRI SAT SUN
END DATE (MM/DD/YYYY)
REQUESTOR/SPONSOR
AGENCY/ORGANIZATION
BUSINESS/DUTY PHONE
SIGNATURE
DATE
REMARKS
III. ACKNOWLEDGEMENT OF INSTALLATION DRIVING PROCEDURES: INITIALS
IV. 117 SFS USE ONLY
ON SRBW DATE OF NCIC/ LETS
CHECK
NCIC OPERATOR COMMENTS
YES
NO
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| NAME Last First Middle: |
| BIRTH MM DD YYYY: |
| SOCIAL SECURITY NUMBER: |
| ETHNICITY: |
| DRIVERS LICENSE NUMBER: |
| STATE: |
| COMPANY UNIT: |
| HOME ADDRESS: |
| TELEPHONE NUMBER: |
| EMAIL ADDRESS: |
| GENDERALIEN PASSPORT NUMBER COUNTRY OF BIRTH NonUS Citizen: |
| START DATE MMDDYYYY: 11/01/2024 |
| END DATE MMDDYYYY: 10/31/2025 |
| MONHours eg 0700 1700: |
| TUESHours eg 0700 1700: |
| WEDHours eg 0700 1700: |
| THURHours eg 0700 1700: |
| FRIHours eg 0700 1700: |
| SATHours eg 0700 1700: |
| SUNHours eg 0700 1700: |
| REQUESTORSPONSOR: Mr. William Hall/ MSgt werkmeister |
| AGENCYORGANIZATION: 117 CES/117 MSC |
| BUSINESSDUTY PHONE: 2300/2347 |
| REMARKS: Security Project - |
| INITIALS: |
| DATE OF NCIC LETS CHECK: |
| NCIC OPERATOR: |
| COMMENTS: |
| Check Box26: Yes |
| Check Box27: Off |
| Check Box28: Off |
| Check Box29: Yes |
| Check Box30: Off |
| Check Box31: Off |
| Check Box32: Off |
| Check Box33: Off |
| Check Box34: Off |
| Check Box35: Off |
| Check Box36: Off |
| Check Box37: Off |
| Check Box38: Off |
| Check Box39: Off |
| HEIGHT ft/in: |
| WEIGHT lbs: |
| EYE COLOR: |
| HAIR COLOR: |
| Text2: |
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