20. SJAFB Access Request Application (2 pages) - EDITABLE.pdf

Contractor Custodial Parent Caretaker

FSS College Instructor

Duties to perform or purpose of request:

Pass Start Date: Pass End Date: (Not to exceed one year.)

( DD / MMM / YYYY ) ( DD / MMM / YYYY )

Check Days Authorized:

Times Authorized:

Section 2- PERSONAL INFORMATION

First Name: MI:

ZIP Code:

Work Number:

Last Name:

Street Address:

City/State:

Home Number:

Driver's License Number/ISSUING STATE:

SSN:

E-Mail:

Vehicle Make: Vehicle Model:

Vehicle Year: License Plate Number/ISSUING STATE:

MI:Last Name: First Name:

Employer/Military Organization: Phone Number:

E-Mail:

Signature:

PRIVACY ACT STATEMENT

Section 1- REASON FOR PASS. Check one.

Vendor

Extended Visitor

Section 4- SPONSOR INFORMATION

FRI

Section 3- VEHICLE INFORMATION

SUN

AUTHORITY: 10 USC 8013, 44 USC 3101 and EO 9397

PRINCIPAL PURPOSE: To record personal information to determine whether a pass should be issued to allow access to the installation.

ROUTINE USES: None

DISCLOSURE IS VOLUNTARY: Failure to disclose the requested information will result in denial of entry onto the installation.

SAT

Are you a US Citizen:

DOB:

THUTUES WEDMON

Gender:

Ethnicity (Optional):

Nationality:

NOTE: Anything other than AMERICAN, a valid Resident Alien Card or Work Visa must be provided

Contractor Sponsor Company:

INSTRUCTIONS

Applicants will complete Sections 2 and 3. Sponsors will complete Sections 1 and 4. Any areas not filled out will delay or deny issuance of pass.

Background checks will take 3-5 business days to complete. Please call 919-722-1345 to check the status of your application.

Required Documents: Driver's License/State ID, vehicle registration, and proof of vehicle insurance card (paper copy or electronic) NOTE: If nationality is listed as anything other than American, the sponsor must provide copy of valid Resident Alien Card or Work Visa.

Custodial Parent/Guardians: Provide the dependent child DD Form 1173, a divorce decree, power of attorney(POA), and/or a child support order, Sponsors CAC/DD Form 1173, or BX/Commissary shopping privilege card.

Base access will be Mon - Sun 0630 to 2200.

Caretakers: Provide a medical POA or a doctor's letter stating the medical condition and duration, sponsors CAC/DD Form 1173.

Base access will be Mon - Sun 0630 to 2030.

Extended Visitor: Provide a memorandum detailing circumstances for request, Sponsors CAC/DD Form 1173.

24/7 base access may be granted but the sponsor must provide proper justification for request.

Date Submitted:

Contract End Date:

Dual Citizen?

Y N

If Yes, Country:

Initial

DCI

Check

Clear Not Clear Clear

DCI Conducted by (Initials and Date) DCI Conducted by (Initials and Date)

Based on the information given should an extended pass be authorized? Approved

Disapproved

Comments:

Based on the information given should an extended pass be authorized? Approved

Disapproved

Comments:

Commander, 4th Security Forces Squadron

DCI Six Month Review

Section 8- 4 SFS/S5V Additional Notes

Pass and ID Use Only

Section 5- 4 SFS/S5V Initial Check

Section 6- 4 SFS/S5B/NCOIC

Section 7- 4 SFS/CC

4SFS/S5B NCOIC

CONTRACTOR ACKNOWLEDGEMENT: UPON SUBMISSION OF THIS APPLICATION THE CONTRACTOR ACKNOWLEDGES THEY WILL BE RESPONSIBLE FOR ANY VIOLATION THAT OCCURS & THAT REJUSTIFICATION IS REQUIRED FOR EXTENSION BEYOND EXPIRATION. ALL DBIDS CREDENTIALS MUST BE COLLECTED BY THE PRIME CONTRACTOR SPONSOR AND RETURNED TO THE VCC UPON EXPIRATION, TERMINATION OF EMPLOYMENT OR IF BASE ACCESS IS NO LONGER NEEDED, FAILURE TO RETURN DBIDS CREDENTIAL WILL RESULT IN A VIOLATION OF AFFARS 5352.242-9000 CONTRACTOR ACCESS TO AIR FORCE INSTALLATIONS AND MAY RESULT IN WITHHOLDING OF

FINAL PAYMENT.

ACKNOWLEDGEMENT FOR EXTENDED VISITORS: UPON SUBMISSION OF THIS APPLICATION THE EXTENDED VISITOR AKNOWLEDGES THAT THIS DBIDS CREDENTIAL GRANTS BASES ACCESS ONLY. IT IS NOT A BENIFITS CARD & DOES NOT GRANT ANY ENTITLEMENT TO MAKE PURCHASES FOR THE REQUESTOR/PATRON OR DESIGNATED DEPENDENT USING THIS CARD. ENTRY INTO AUTHORIZED FACILITIES IS DONE ON BEHALF OF THE SPONSOR. DBIDS CREDENTIALS MUST BE COLLECTED BY THE SPONSOR AND RETURNED TO THE VCC UPON EXPIRATION, TERMINATION OF EMPLOYMENT OR IF BASE ACCESS IS NO LONGER NEEDED. FAILURE OF TO RETURN DBIDS

CREDENTIAL MAY RESULT IN WITHHOLDING OF FUTURE DBIDS CREDENTIALS

Not Clear