Atch(3)_Escort Request Form_Entry-Exit.pdf

THIS FORM SHALL BE SUBMITTED WITH COMPLETED 1-DAY OFFICIAL ENTRY/EXIT REQUEST

Name of Escorter : Grade: DoD ID#

Name of Sponsor : Grade: DoD ID#

Organization : TEL# RTD:

MM/YY

Destination: From: To:

Time / Date Time / Date

Purpose of Request:

**日本語で記入する場合、名前及び国籍は英語表記でも記入すること / You can fill out all in Japanese except guests name and nationality.

**17歳以下で親の同伴がない場合は承諾書が必要/ Children 17 years old or younger traveling without their parents need to attach signed “Permission Statement”

H-1

3) Facility access is contingent upon MCX and DECA policy and should be addressed with each facility directly.

4) Those guest(s) who attend club activities must check out and exit the Air Station within 30 minutes of respective club's closing.

5) A violation of this authorization may result in disciplinary action up to termination of sponsorship privilages.

Work / Cell Phone

ADDRESS, TEL#

(住所、電話番号)

PLACE OF

WORK

"For Official Use Only - Privacy Sensitive : Any misure or unauthorized disclosure may result in both civil and criminal penalties"

Approving Official

PRINT NAME

Sponsor's Signature

1) GUEST(S) MUST BE ESCORTED AT ALL TIMES WHILE ON THE INSTALLATION. PASS(ES) MUST BE RETURNED TO THE MAIN GATE SENTRY WHEN

YOUR GUEST(S) EXIT THE AIR STATION.

2) Your respective guest(s) must check in upon entering the Air Station and be issued a visitor's pass. A Vailed picture

I.D. is requred at Main Gate when checking in.

DOB(生年月日)DD/MM/YY,AGE (歳)

BADGE#

APPENDIX H MCASO 5500.2V

1-DAY OFFICIAL ENTRY/EXIT REQUEST Date:______________ (Must Submit to PMO Admin DURING WORKING HOURS 3 BUSINESS DAYS IN ADVANCE)

NATIONALITY

PASSPORT#

VEH#

PRINT NAME OF GUEST（氏名）

QTRS#

REVISION Ver.1(14Jan2016)

Name of Escorter : Grade: DoD ID#

Name of Sponsor : Grade: DoD ID#

Organization : TEL# RTD:

MM/YY

Destination: From: To:

Time / Date Time / Date

Purpose of Request:

** / You can fill out all in Japanese except guests name and nationality.

**17 / Children 17 years old or younger traveling without their parents need to attach signed “Permission Statement”

H-1

3) Facility access is contingent upon MCX and DECA policy and should be addressed with each facility directly.

4) Those guest(s) who attend club activities must check out and exit the Air Station within 30 minutes of respective club's closing.

5) A violation of this authorization may result in disciplinary action up to termination of sponsorship privilages.

Work / Cell Phone

ADDRESS, TEL#

PLACE OF

WORK

"For Official Use Only - Privacy Sensitive : Any misure or unauthorized disclosure may result in both civil and criminal penalties"

Approving Official

PRINT NAME

Sponsor's Signature

1) GUEST(S) MUST BE ESCORTED AT ALL TIMES WHILE ON THE INSTALLATION. PASS(ES) MUST BE RETURNED TO THE MAIN GATE SENTRY WHEN

YOUR GUEST(S) EXIT THE AIR STATION.

2) Your respective guest(s) must check in upon entering the Air Station and be issued a visitor's pass. A Vailed picture I.D. is requred at Main Gate when checking in.

DOB( )DD/MM/YY,AGE ( )

BADGE#

APPENDIX H MCASO 5500.2V

1-DAY OFFICIAL ENTRY/EXIT REQUEST Date:______________ (Must Submit to PMO Admin DURING WORKING HOURS 3 BUSINESS DAYS IN ADVANCE)

NATIONALITY

PASSPORT#

VEH#

PRINT NAME OF GUEST

QTRS#

REVISION Ver.1(14Jan2016)

Sample

Sample Sample Sample Sample Sample Sample Sample

Sample Sample Sample Sample

Sample Sample Sample Sample Sample

Sample

Taro IWAKUNI 岩国太郎 25/04/80, 39

Japanese Passport# xxxxxxx

1-2-3, Iwakuni, Yamaguchi, Japan 0827-79-xxxx

ABC

Corporation

Yamaguchi

400 WA 12-34

SAMPLE

ID type (passport or driver's license) and its number

Valid Picture ID:

"Passport (original)" or "Driver's License WITH original Jyumin Hyo with permanent address (Honseki-chi)"

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