ANNEX D - Installation Access Waiver Denial Appl..pdf

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 ___.