Atch 5_BSFB Form 128 Template.pdf

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ODR Countertop & Cabinets Replacement
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FA254326Q0035
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This is a REQUEST FOR VISITOR TO OBTAIN UNESCORTED ACCESS TO BUCKLEY SPACE FORCE BASE form (BUCKLEY SFB FORM 128) used by the 460th Security Forces Squadron, Installation Access Control Section to process guest access requests to the installation. The form operates under the authority of 10 U.S.C. 8013 and 5 U.S.C 552a and is subject to the Privacy Act Statement of 1974.

The form requires completion of three sections: Section I requests sponsor information including name, DOD ID number, unit, phone number, visit dates, duration, and reason for visit; Section II requests guest information including name, date of birth, driver's license number, state of issuance, and U.S. citizenship status; and Section III is completed by 460th Security Forces Installation Access Control Staff to document the NCIC check date, approving official, and signature. Key submission requirements mandate that all information be complete and in alphabetical order, guests must present government or state identification, sponsors must be pre-registered in DBIDS, and forms must be submitted 72 duty hours prior to the requested visit date, with an additional 24 duty hours required for every additional page. Disclosure of requested information is voluntary; however, failure to provide complete information may result in denial of the access request.

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REQUEST FOR VISITOR TO OBTAIN UNESCORTED ACCESS TO BUCKLEY SPACE FORCE BASE

(THIS FORM IS SUBJECT TO THE PRIVACY ACT STATEMENT OF 1974)

AUTHORITY: 10 U.S.C. 8013; 5 U.S.C 552a PURPOSE: To assist security personnel in establishing a fitness determination through the identity proofing and vetting process.

INTENDED USE: To be utilized by personnel requesting to obtain guest installation access pass for unescorted access to Buckley Space Force Base (BSFB).

DISCLOSURE: Disclosure of requested information is voluntary, however failure to provide information may result in denial of request and the refusal by the 460th Security Forces Squadron, Installation Access Control Section to permit access to the installation.

INSTRUCTIONS

1. All information must be complete and in alphabetical order or the form will be denied.

2. Guest must present government/state ID in order to establish identity.

3. Sponsor must be registered in DBIDS prior to submitting form.

4. Must be submitted to Access Control Staff 72 duty hours prior to request and an additional 24 duty hours for every additional page.

SECTION I: SPONSOR INFORMATION

SPONSOR NAME (Last, First, MI) SPONSOR DOD ID NUMBER SPONSOR UNIT SPONSOR PHONE NUMBER

Visit Start Date (MM/DD/YYYY) Visit End Date (MM/DD/YYYY) Number of Days REASON FOR VISIT

SECTION II: GUEST INFORMATION

GUEST NAME (Last, First, MI) DOB (MM/DD/YYYY) DRIVERS LICENSE # STATE U.S. CITIZEN (Yes/No. If not, what country?)

Approved (Yes/No)

SECTION III: TO BE COMPLETED BY 460TH SECURITY FORCES INSTALLATION ACCESS CONTROL STAFF DATE NCIC CHECK CONDUCTED APPROVING OFFICIAL (Last, First, MI) SIGNATURE

BUCKLEY SFB FORM 128 Page # of

1568028666A Cross-Out

SPONSOR UNIT: 460th CONS
SPONSOR PHONE NUMBER: 720-847-9953
DOB MMDDYYYY:
STATEDRIVERS LICENSE:
US CITIZEN YesNo If not what countrySTATE:
Approved YesNoUS CITIZEN YesNo If not what country:
DOB MMDDYYYY_2:
STATEDRIVERS LICENSE_2:
US CITIZEN YesNo If not what countrySTATE_2:
Approved YesNoUS CITIZEN YesNo If not what country_2:
DOB MMDDYYYY_3:
STATEDRIVERS LICENSE_3:
US CITIZEN YesNo If not what countrySTATE_3:
Approved YesNoUS CITIZEN YesNo If not what country_3:
DOB MMDDYYYY_4:
STATEDRIVERS LICENSE_4:
US CITIZEN YesNo If not what countrySTATE_4:
Approved YesNoUS CITIZEN YesNo If not what country_4:
DOB MMDDYYYY_5:
STATEDRIVERS LICENSE_5:
US CITIZEN YesNo If not what countrySTATE_5:
Approved YesNoUS CITIZEN YesNo If not what country_5:
DOB MMDDYYYY_6:
STATEDRIVERS LICENSE_6:
US CITIZEN YesNo If not what countrySTATE_6:
Approved YesNoUS CITIZEN YesNo If not what country_6:
DOB MMDDYYYY_7:
STATEDRIVERS LICENSE_7:
US CITIZEN YesNo If not what countrySTATE_7:
Approved YesNoUS CITIZEN YesNo If not what country_7:
DOB MMDDYYYY_8:
STATEDRIVERS LICENSE_8:
US CITIZEN YesNo If not what countrySTATE_8:
Approved YesNoUS CITIZEN YesNo If not what country_8:
DOB MMDDYYYY_9:
STATEDRIVERS LICENSE_9:
US CITIZEN YesNo If not what countrySTATE_9:
Approved YesNoUS CITIZEN YesNo If not what country_9:
DOB MMDDYYYY_10:
STATEDRIVERS LICENSE_10:
US CITIZEN YesNo If not what countrySTATE_10:
Approved YesNoUS CITIZEN YesNo If not what country_10:
DOB MMDDYYYY_11:
STATEDRIVERS LICENSE_11:
US CITIZEN YesNo If not what countrySTATE_11:
Approved YesNoUS CITIZEN YesNo If not what country_11:
DOB MMDDYYYY_12:
STATEDRIVERS LICENSE_12:
US CITIZEN YesNo If not what countrySTATE_12:
Approved YesNoUS CITIZEN YesNo If not what country_12:
DOB MMDDYYYY_13:
STATEDRIVERS LICENSE_13:
US CITIZEN YesNo If not what countrySTATE_13:
Approved YesNoUS CITIZEN YesNo If not what country_13:
DOB MMDDYYYY_14:
STATEDRIVERS LICENSE_14:
US CITIZEN YesNo If not what countrySTATE_14:
Approved YesNoUS CITIZEN YesNo If not what country_14:
DOB MMDDYYYY_15:
STATEDRIVERS LICENSE_15:
US CITIZEN YesNo If not what countrySTATE_15:
Approved YesNoUS CITIZEN YesNo If not what country_15:
DOB MMDDYYYY_16:
STATEDRIVERS LICENSE_16:
US CITIZEN YesNo If not what countrySTATE_16:
Approved YesNoUS CITIZEN YesNo If not what country_16:
DOB MMDDYYYY_17:
STATEDRIVERS LICENSE_17:
US CITIZEN YesNo If not what countrySTATE_17:
Approved YesNoUS CITIZEN YesNo If not what country_17:
DOB MMDDYYYY_18:
STATEDRIVERS LICENSE_18:
US CITIZEN YesNo If not what countrySTATE_18:
Approved YesNoUS CITIZEN YesNo If not what country_18:
DOB MMDDYYYY_19:
STATEDRIVERS LICENSE_19:
US CITIZEN YesNo If not what countrySTATE_19:
Approved YesNoUS CITIZEN YesNo If not what country_19:
DOB MMDDYYYY_20:
STATEDRIVERS LICENSE_20:
US CITIZEN YesNo If not what countrySTATE_20:
Approved YesNoUS CITIZEN YesNo If not what country_20:
DOB MMDDYYYY_21:
STATEDRIVERS LICENSE_21:
US CITIZEN YesNo If not what countrySTATE_21:
Approved YesNoUS CITIZEN YesNo If not what country_21:
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