3i_Leisure Foreign Visitor Request Questionnaire 2020.pdf

DEPARTMENT OF THE AIR FORCE

HEADQUARTERS 36TH WING (PACAF)

ANDERSEN AIR FORCE BASE GUAM

Foreign National Access Request Form Leisure Request

APPROVED BY: ___________________________ FVR NUMBER: _________________

SPONSOR

(AD, Guard, Res, Civ)

SECONDARY SPONSOR

(Dependent, AD, Guard, Res, Civ) First Name

Last Name:

Date of Birth:

DD MMM YYYY

RANK

DD MMM YYYY

RANK

Contact Phone Number:

SSN:

Organization:

Home Address:

Street

, Guam City ZIP

Street

, Guam _ City ZIP

Visitor’s intended location on Andersen:

Visitor 1 Visitor 2 Visitor 3 First Name:

Last Name:

Date of Birth: / /

DD / MMM / YYYY

DD / MMM / YYYY

DD / MMM / YYYY

Country of Citizenship:

Identification Type [] Passport [] I-94 [] U.S. Visa [] Other:_________

[] Passport [] I-94 [] U.S. Visa [] Other:_________

[] Passport [] I-94 [] U.S. Visa [] Other:_________

Occupation:

Place of Employment:

Relationship to Escort:

How long is your stay on Andersen

AFB

From:___________/___________/_________

DD MMM YYYY

To:___________/____________/___________

DD MMM YYYY

From:___________/___________/___________

DD MMM YYYY

To:___________/____________/____________ DD MMM YYYY

From:___________/___________/___________

DD MMM YYYY

To:___________/____________/____________ DD MMM YYYY Purpose of visit to Andersen?

Address while on Guam:

Street

________________________________________, Guam ____________________ City Zip

Street

________________________________________, Guam ____________________ City Zip

Street

________________________________________, Guam ____________________ City Zip

PRIVACY ACT STATEMENT: AUTHORITY: Title 5 USC Section 301, Departmental Regulation Principle Purpose: To record personal information and determine access to the installation ROUTINE PURPOSE: To request and record the issuance of a Visitor Pass when the use of another form is not authorized or specified. Failure to provide any information requested may result in non-issuance of the Visitor Pass. Disclosure of information is voluntary acceptance of these terms constitutes approval for a background check to be conducted as part of the request approval process. The information is necessary for validation of identity and determination of entry eligibility on to Andersen Air Force Base. Failure to provide this information may result in non-issuance determination by the issuing authority.

Date Approved: ______________

Date Modified: 18 Feb 2020