26QA100 Attachment IV - DRAFT 648-C Request for Access to Tobyhanna Army Depot.pdf

Page 1 of 2Previous editions are obsolete.ELTY FORM 648-C, MAR 2025

Request for Access to Tobyhanna Army Depot Use in accordance with Directive Type Memorandum (DTM) 09-0012 "Interim Policy Guidance for DoD Physical Access Control" dated 22 APR 14.

Proponent Office is ELTY-ISR-S.

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 United States Code, Section 3013

PRINCIPAL PURPOSE:

In conjunction with "Directive Type Memorandum (DTM)" 09-012 "Interim Policy Guidance for DoD Physical Access Control", dated 22 Apr 14, this form is intended to ensure that force protection measures are implemented for all non-DoD - credentialed personnel who request access to the installation.

ROUTINE USES: To control and maintain force protection requirements.

DISCLOSURE:

Voluntary civilian. Failure to provide information deemed "mandatory" may result in a processing delay of your request for access or a denial of your request.

APPLICATION

DATE

REASON FOR REQUEST

FOR CRIMINAL HISTORY BACKGROUND CHECK

DATE OF ANTICIPATED VISIT OR YELLOW

CONTRACTOR BADGE EXPIRATION DATE

AREAS OF TYAD

TO BE VISITED

FIRST NAME MIDDLE NAME LAST NAME

STREET ADDRESS PHONE NUMBER

CITY STATE ZIP CODE DRIVER'S LICENSE

STATE DRIVER'S LICENSE NUMBER

RACE SEX DATE OF BIRTH STATE OF BIRTH COUNTRY OF BIRTH SOCIAL SECURITY NUMBER

OTHER NAMES USED / ALIASES

TOBYHANNA FEDERAL EMPLOYEE POINT OF CONTACT (POC)

POC NAME POC PHONE NUMBER POC EMAIL ADDRESS

POC DIRECTORATE

CRIMINAL HISTORY BACKGROUND CHECK RELEASE AND CONSENT

I hereby authorize the Tobyhanna Army Depot Security Branch to receive any criminal history/background information pertaining to me which may be in the files of any Federal, State or Local criminal justice agency/organization. I understand that a criminal history background check will be used to determine access to Tobyhanna Army Depot and that access to Tobyhanna Army Depot can be revoked at any time.

PLEASE TAKE NOTICE THAT ONE OR MORE CRIMINAL BACKGROUND REPORTS PURSUANT TO THE FAIR CREDIT REPORTING ACT, AS AMENDED, 15 U.S.C. 1681 ET SEQ, MAY BE OBTAINED FOR THE PURPOSES OF ACCESS TO TOBYHANNA ARMY DEPOT. SHOULD A DECISION TO DENY ACCESS BE MADE BASED EITHER IN PART OR IN WHOLE ON THAT REPORT, THE REPORTING AGENCY THAT PROVIDED THE

INFORMATION PLAYED NO ROLE IN THE DECISION.

Information provided by you on this form will be furnished to Tobyhanna Army Depot's Security Branch to obtain information in connection with an investigation to determine access to Tobyhanna Army Depot. This information is collected for national security and force protection purposes. Use of this form does not relieve any contractor of any requirement to perform a criminal background check or drug test.

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Page 2 of 2Previous editions are obsolete.ELTY FORM 648-C, MAR 2025

Please answer the following questions and report information truthfully; regardless of whether your case has been "sealed", expunged, or otherwise stricken from the court record. The single exception to this requirement is certain convictions under the Federal Controlled Substances Act-cases for which the court has issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607.

If the answer is "yes" to any of these questions, please list the actual offense or violation (for example: theft, DUI, battery, etc.).

1. Are you currently barred from ANY military installation?

2. Have you ever been arrested for, charged with, or convicted of a sex offense? Are you a registered sex offender?

3. Have you ever been charged with or convicted of a felony?

4. Have you ever been charged with or convicted of a firearms, weapons, or explosives offense?

5. Have you ever been charged with or convicted of any offense related to alcohol or drugs?

6. In the last 7 years, have you been subject to a court martial or other disciplinary proceedings under the Uniform Code of Military Justice?

(Include non-judicial, Captain's mast, etc.)

7. In the last 10 years, have you been arrested for, charged with, or convicted of any other offense not listed above?

(Include misdemeanors; Leave out traffic fines of less than $150 unless the violation was alcohol or drug related.)

8. Are you currently on parole or probation?

9. Are you a United States Citizen?

APPLICANT CERTIFICATION

I certify that, to the best of my knowledge and belief, all of the information provided on this request for access to Tobyhanna Army Depot is true, correct, complete and made in good faith. I understand that false, fraudulent, or incomplete information may be grounds for the denial of my request or for the revocation of access to Tobyhanna Army Depot and may be punishable by fine or imprisonment. I understand that any information I provide may be investigated.

APPLICANT NAME (PRINT)

APPLICANT SIGNATURE DATE

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