Atch 7 - Form 5000.pdf
PDF 84 KB Posted
- Attached to
- Survivability Test Stand
- Solicitation number
- FA910126RB005
About this file
This is a Directorate of Emergency Services Access Control Background Check Request Form used by White Sands Missile Range to process personnel access requests. The form collects personal identification information across seven sections: last name, first name, middle name or initials, sex, date of birth, driver's license or ID card number with state of issue, and place of birth.
The form operates under the authority of 10 U.S.C. 3103 and Army Regulation 190-13 (Army Physical Security Program). Its principal purpose is to determine suitability of individuals requesting facility access by generating state and federal criminal history record checks. The information collected may be disclosed to appropriate military and civilian emergency and investigation agencies to support access determination decisions. Submission of information is voluntary; however, failure to provide the requested information may result in denial of access to White Sands Missile Range. The form includes a multi-row table structure designed to accommodate multiple individual entries for batch background check processing.
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Text version
Sec 1. Sec 2. Sec 3. Sec 4. Sec 5. Sec 6. Sec 7.
LAST NAME FIRST NAME MIDDLE NAME or (NMN) Sex (M/F) DATE OF BIRTH MM-
DD-YY
DL or ID CARD NUMBER & State of Issue PLACE OF BIRTH (City, State or Country)
Directorate of Emergency Services Access Control Background Check Request Form
Privacy Act Statement: AUTHORITY: 10 U.S.C. 3103; and Army Regulation 190-13, Army Physical Security Program. PRINCIPAL PURPOSE: To determine suitablilty of individual(s) requesting access to White Sands Missile Range. This information will be sued to generate state and federal criminal history record checks. ROUTINE USE(S): Personal information may be disclosed to appropriate military and civilian emergency and investigation agencies to assist in determining suitability for acces to White Sand Missile Range. DISCLOSURE: Voluntary. However, failure to provide information could result in the refusal to access White Sands Missile Range.
Table 1
File details come from the government source that posted it. Updated .