55R_Entry Authorization and Badge Request(1NOV21).pdf

Subcontractor:

LAW ENFORCEMENT & SECURITY PROCESSING

Records Check: Bar List Check: PMO Officer:

Entry & Exit Officer:

CAC/DOD ID Number: Purpose of Travel: Carrier:

AMC use only: Manifest: Mission:

Arrival: Departure: Emergency Contact:

Relationship: Address:

City: State:

Sponsor (on-island):

Email: Phone Number:

Traveler Signature:

BADGE INFORMATION

Position: Rank/GS (Equivalent): Sex: Race:

Height: Weight: Eyes: Hair:

Phone: PO Box:

Number of Dependents listed on orders: Traveling with a pet: Type:

Authorized Permissions: Meal Card Holder: Surfway Access:

Permissions Authorized By: Signature:

ACCESS TO RESTRICTED AREAS

Fuel Pier: Meck Island Echo Pier: Yokohama Pier: Outer Islands:

Badge Type:

Company Security Representative/ Company Program Manager:

ATI/AMC Passengers: It is important that you confirm your reservation with the Honolulu Office (808)-422-6447 three (3) days prior to your departure from Hickam AFB. The SOFA and USAG-KA Regulation 190-10, 3.2.1 prohibits the importation and possession of firearms, ammunition, and explosives at USAG-KA by persons not specifically authorized in writing. Violators of this regulation will face adverse administrative actions.

Privacy Act Statement: This form is affected by the Privacy Act of 1974. The information requested herein is solicited under authority of 10 USC 3013. The purpose is to permit determination of an individual’s citizenship status, if the individual is authorized to visit USAG-KA/RTS, and to create a means of identification of all individuals entering. In addition, the information may be disclosed to any element of DoD which may be concerned with the approvals, disapprovals, or revocations of entry authorizations. The information may be disclosed to the Justice Department if it appears the information furnished may be false or may constitute a violation of federal law.

Disclosure of the information is not mandatory but failure to do so will result in the delay of processing and may result in denial of entry.

HR Manager: Signature:

Facility Owner: Signature:

Residence/Quarters:

(If Known, If not please bring to badging office)

Sponsor Phone Number: Sponsor Quarters number:

SSN:

(last four)

PLACE OF BIRTH:

(City, State)

Organization/Company:

TRAVELER:

CITIZENSHIP:

Personnel Type:

(Feet) (Inches)(Feet) (Inches)

Last, First, Middle Initial)

DOB:

November 2021

SFTT WMS

Date:

Approved Denied Date:

Remarks:

Resident Status:

Section 2

Section 3

Section 4

USAG-KA Form 55R

REQUEST AND AUTHORIZATION FOR ENTRY: US Army Garrison – Kwajalein Atoll

Request Type: Date:

Section 1

Schedule (Days, Horus)

(To get number, dial 19097 from BQ/Home)

H W

(last four)

Subcontractor:

Name: DOB: SSN: (last four)

Citizenship: Place of Birth: Relation to Traveler:

Sex: Race: Height: Weight: Eyes: Hair:

Name: DOB: SSN: (last four)

Citizenship: Place of Birth: Relation to Traveler:

Sex: Race: Height: Weight: Eyes: Hair:

Name: DOB: SSN: (last four)

Citizenship: Place of Birth: Relation to Traveler:

Sex: Race: Height: Weight: Eyes: Hair:

Name: DOB: SSN: (last four)

Citizenship: Place of Birth: Relation to Traveler:

Sex: Race: Height: Weight: Eyes: Hair:

Name: DOB: SSN: (last four)

Citizenship: Place of Birth: Relation to Traveler:

Sex: Race: Height: Weight: Eyes: Hair:

Garrison Command Sergeant Major: Signature:

Comma nd Sponsorship: Approved Disapproved Not Applicable

I certify that Command Sponsorship has been obtained for the individuals listed above.

Attachments:

USAG-KA Command Sponsorship Checklist Dependent Sponsorship Letter Marriage Certificate

Dependent/Sponsor Passports

School Admission Approved Letter Last 4 of SSN Medical Clearance forms

SSN:

PLACE OF BIRTH:

(City, State)

Organization/Company:

TRAVELER:

CITIZENSHIP:

Personnel Type:

DOB:

Last, First, Middle Initial)

November 2021

Date:

REQUEST AND AUTHORIZATION FOR ENTRY: US Army Garrison – Kwajalein Atoll

USAG-KA Form 55R

Section 5

U.S. Army Garrison Kwajalein Atoll 55R Instructions The following are instructions on how to properly fill out the USAG-KA Form 55R to ensure timely processing prior to entry into USAG- Kwajalein Atoll.

Section 1. This section provides basic information on the traveler.

Request Type: This section describes the nature of why the form is being created. Please select from the drop down menu. Entry and Badge Request_New Hire this selection is for personnel who have never been to Kwajalein and were recently hired or placed on orders to Kwajalein Atoll. Badge Request Only select for badge renewals/lost misplaced badges/or unreadable badge to be replaced. Entry Only Returning Resident select this if you are a returning Kwajalein Resident and your badge is not expired. Exit_DEMOB select this if you are leaving Kwajalein and concluding your tour on Kwajalein. Exit_TDY_R&R select this is you are leaving Kwajalein for TDY or R&R Date: Drop down Calendar select the current date that you are completing the form. Traveler: Self Explanatory. SSN: only provide the Last 4 digits of your SSN. DOB: Select from Drop down Calendar. Citizenship: Self Explanatory. Place of Birth: City, State. Personnel Type: Self Explanatory. Organization: Company/Unit Assigned. Arrival Date: select the date traveler will arrive on Kwajalen. Departure: for new hires/R&R/TDY date you depart Hawaii. For exit Date you depart Kwajalein. Emergency Contact Information: In this section provide an emergency point of contact. Name, relationship, address, city,state, email and phone number. The USG will use this information if notifications are necessary. Traveler's Signature: Traveler will sign this portion of the form upon arrival to USAG-KA prior to badge issuance. Sponsor (On-Island): your Human Resources Representative should assign you a sponsor to help you throughout your move to Kwajalein and help you acclimate to the island. Contact your HR representative if you do not have this information.

Section 2: Badging Information Position: fill in your job title. Rank/GS Equivalent: fill in if known. Sex: Type in. Race: Type in.

Height, Weight, Eyes, Hair: Self explanatory. Residence/Quarters/Phone/PO Box: If unknown at time of form completion bring address with you to Badging Office. Number of Dependents: Drop-down menu for number traveling. Pets and Type: enter yes, no, or n/a, if yes enter pet type i.e. cat, dog, etc..

The Following are to be completed by authorized HR representatives IAW Resident Status: to be filled in by HR Rep. Meal card holder: To be filled out by HR Rep based on ISSA. Surfway Access: To be filled out by HR Rep based on ISSA. Permissions Authorized by: Name and Signature of authorized HR representative per USAG-KA HR Memorandum for Record.

Section 3. Traveler will not fill in this section. This section will be filled out by Company HR Reps. Instructions for HR Reps: if access is required for any of the four areas please use the following selections.

(1.) Access is required because the facility is his/her appointed daily place of work. (2.) Visitation of the facility is required at least three times per week for the purpose of conducting official business. (3.) Access to a particular facility is required to perform supervisory/management overview.

(4.) Not applicable.

For C-Badge workers input work schedule. Company Security Representative/Company Program Manager: Signature is required by security representative to verify clearance requirements. If the company has no Security Representative the Program Manager can sign. Facility Owner/ Signature: HR Reps will ensure the facility owner has approved use of areas if required to perform work/oversight by approved facility owners..

Section 3 Continued: After HR Rep has received approved Facility Owner's Signature they will sign the form. The HR Rep will then digitally send the form to the PMO inbox for routing if Traveler is Unaccompanied.

Section 4: TO BE COMPLETED BY THE PROVOST MARSHALLS OFFICE AND ENTRY & EXIT

Section 5: If the traveler is Accompanied traveler will input standard information as they did in section 1. The traveler will then fill out dependent family information for all travelers. This information is used for badging and verification. Dependents 10 years of age and older will receive badges in accordance with USAG-KA Reg 190-10.

Attachments: The following are required for all dependent travelers to be approved by the Garrison CSM. Marriage Certificate Medical Clearance Forms Dependent/Sponsor Passports/Last 4 of SSN School Admission Approval Letter Traveler will provide digital copies of the above documents. Once HR receives copies of the documents along with the 55-R form the HR will email the complete packet to the Provost Marshall's Office. This form needs to be completed prior to any travel to Hawaii. To prevent delays in processing these documents are required to be received 14 days prior to the travelers arrival in Hawaii.