TE 05 DES Form.pdf

REQUEST FOR A FORT STEWART/HUNTER ARMY AIRFIELD ACCESS

CONTROL CARD OR EXTENDED PASS

PRIVACY ACT ADVISEMENT: The information requested is for the purpose of granting access to the Fort Stewart/Hunter Army Airfield Installation. Providing requested information, to include your social security number (SSN), is voluntary. However, your access may not be granted if all requested information is not provided. AUTHORITIES: Executive Orders (EO) 10450, 10865, and 12333. The SSN, required for record accuracy, is requested pursuant to EO 9397. I hereby authorize Fort Stewart Police Department to receive any Criminal History Record information pertaining to me which may be in files of any state or local criminal justice agency in Georgia.

1.

FIRST Name:______________________ MIDDLE Initial: __________

DOB:____________________ Race: __________________

APPLICANT INFORMATION:

LAST Name:___________________________

Social Security Number:___________________

Gender (Check one): Driver's License # _________________________ State: ________________

Street Address:_____________________________________ Home or Cell Phone Number: _________________________

E-Mail Address: (Optional)_____________________________ Relationship to Sponsor:_____________________________

2. REQUESTED CARD:

Non-DoD Contractor Foreign National Friends of the Marne Vendor Family Care Provider MWR Gate-to-Gate Parent of Marne Child Other

3. REQUESTED DATE:

4. JUSTIFICATION FOR ACCESS CARD OR EXTENDED PASS:

5. SPONSOR INFORMATION:

LAST Name: FIRST Name: MIDDLE Initial:

Grade/Rank/Status: DOB: Gender (check one):

Organization/Unit: Organization/Unit Phone Number:

Home or Cell Phone Number: E-Mail Address:

6. SPONSOR CERTIFICATION: I certify that the applicant meets the justification requirements as indicated in paragraph 3 above for access privileges.

Printed Name: Government Sponsor Signature:

7. NCIC (GCIC) OPERATOR:

Last Name/Initials/Date: Derogatory Non-Derogatory No History

****** SECTION BELOW IS FOR USE BY THE DES SECURITY DIVISION ONLY******_______

8. ISSUING OFFICIAL INITIALS: APPROVED DISAPPROVED

Issuing Official Printed Name: Issuing Official Signature: Date:

IMSH FORM 2737-E-R

13 FEB 2015

Male Female

Male Female

TO: FROM: