ANNEX D - Installation Access Waiver Denial Appl. (1).pdf
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- Solicitation number
- 47QMCA25Q0035
- Issued by
-
GSA Federal Acquisition Service
About this file
The document is an Installation Access Denial Waiver Application form for White Sands Missile Range's Visitor Control Program. This two-page form requires an individual to provide comprehensive personal information, including full contact details, criminal history, and reasons for requesting access to the missile range facility. The form mandates disclosure of complete criminal records (excluding traffic infractions), court documents, and detailed explanations of any felony convictions, with sections requiring the applicant to explain circumstances that might mitigate their criminal history and demonstrate rehabilitation.
The application includes a verification section where the applicant must sign under penalty of perjury, affirming the truthfulness of the information provided, and requires notarization. Key sections include questions about previous federal facility access denials, references the applicant wants contacted, and spaces for explaining the context of criminal history. The form warns that any misrepresentation or omission of information may result in denial of the access request, emphasizing the rigorous screening process for entry to White Sands Missile Range.
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Text version
ANNEX D (Installation Access Denial Waiver Application) to White Sands Missile Range Visitor Control Program
INSTALLATION ACCESS DENIAL WAIVER APPLICATION
WARNING: ANY MISREPRESENTATION OR OMISSION OF INFORMATION MAY RESULT
IN DENIAL OF THE REQUEST
INSTALLATION ACCESS DENIAL WAIVER REQUEST FORM
Please type or print neatly; Attach additional sheets if necessary
1. Name (First/Middle/Last)
2. Current Address (Number and Street, City, State, and ZIP Code)
3. SSN: DOB:
4. Email address:
Do you want your decision emailed back to you rather than mailed to you? ____ Yes
5. Current Telephone Number Home ( )______-___________ Work (____)______-__________
6. Reason for requesting access to White Sands Missile Range
7. What job will you perform at White Sands Missile Range?
8. Does your job require you to have a government issued security clearance?
9. List Your ENTIRE Criminal History (except traffic and other infractions) as follows:
CRIME FOR WHICH
YOU WERE
ARRESTED
CRIME FOR WHICH
YOU WERE
CONVICTED (OR
INDICATE IF
DISMISSED OR
NULL PROS.)
NAME & ADDRESS
OF COURT OR
AGENCY
DISPOSITION (INCLUDE
SENTENCE AND
CONVICTION DATE)
10. Attach a copy of all court documents, certified by the Clerk of the Court, for all of your conviction(s).
11. In your own words, explain the facts of each felony, and why you should be able to come on post. Attach as many additional sheets as necessary.
12. Explain any circumstances that lessen the seriousness of the felony conviction(s) and show that you have been rehabilitated. Attach additional sheets if necessary.
ANNEX D (Installation Access Denial Waiver Application) to White Sands Missile Range Visitor Control Program
13. Have you been denied access by any other federal facility? (please circle)
Yes No
If yes, indicate the reason for the denial.
14. List all references that you would like the government to contact on your behalf. Include name, address, telephone number, and relationship:
VERIFICATION
State of (____________________) County of (_____________________) Under the penalty of perjury, the undersigned has examined this request for review and to the best of my knowledge and belief, it is true, complete, and correct.
Your Signature
Your printed name
Date (Month, Day, Year)
Before me, the undersigned, a Notary Public in and for said County and State, personally appeared _________________________ and acknowledged the execution of the foregoing instrument as his/her voluntary act and deed.
WITNESS, my hand and Notarial Seal, this ____ day of _______, 20 ___.
File details come from the government source that posted it. Updated .