Attach 5 -Form 190-13-2 Fort Detrick Installation Access Badge Request.pdf

Sponsor’s Name (Last, First, MI)

Title

Unit/Organization/Tenant (Non-affiliated resident put Detrick Homes) Phone

Signature Date

COMPLETED BY SPONSOR

FORT DETRICK INSTALLATION ACCESS BADGE REQUEST FORM

This card type is for

GOLD STAR

FAMILIES.

This card type is for Fort Detrick affiliated personnel who do not possess a issued/ working CAC/PIV.

This card type is for residents of Fort Detrick Homes.

This card type is for visitors who have a business need to enter Fort Detrick without an affiliation.

TYPES OF BADGES COMPLETED BY APPLICANT

Name (Last, First, MI)

Street Address

City State Zip Code

Unit/Organization/Tenant (Non-affiliated resident put Detrick Homes)

Building/House Number Work Phone Cell Phone

Signature

Date

COMPLETED BY VCC

Issue Date Expiration Date

AIE System Administrator’s Name

Privacy Act Statement ~ 5 U.S.C Section 5701, 5702, and Executive Order 9397, authorized collection of this information. The primary use of this information is by the Directorate for Public Safety to approve applications/requests for Fort Detrick Installation Access Badges.

Furnishing data, is voluntary, but failure to do so may delay or preclude timely access to the installation, and may delay or preclude timely access to Government controlled buildings and/or communications systems.

FORT DETRICK FORM 190-13-2, DEC 2023

PERMANENT

VISITOR

SURVIVOR

ACCESS

DOE

JOHN

This card can be registered at mul ple installa ons