ATTACH_03_23-R-0004_WGR_FrBrk_Base_Access_Request_Form.pdf

Application For Defense Biometric Identification System (DBIDS) Access Credential

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

AUTHORITY: Title 10, United States Code 8012.

PRINCIPLE PURPOSE: To assist security personnel in establishing a fitness determination through the identity proofing and vetting (background check) process. Guest’s signature on this form constitutes consent of NCIC background check.

INTENDED USE: To be utilized by personnel requesting to obtain guest installation access credential for unescorted access to Atlantic City, ANGB.

DISCLOSURE: Disclosure of requested information is voluntary; however, failure to provide information may result in denial of request or the refusal by the 177th Security Forces Squadron, Pass and ID section (177 SFS/S5) to permit issuance of an installation access credential. By signing this application, the applicant understands if they lose their installation access credential, they will report the loss immediately to their sponsor and the Base Defense Operations Center (BDOC) Controller, 761-6222.

INSTRUCTIONS

1. All information must be completed or the form will be denied.

2. Guest must present Government issued photo ID in order to establish Identity.

3. Sponsor MUST be registered in DBIDS prior to submitting form and ensure all blocks are complete.

SECTION I: REQUESTING AUTHORITY

First MI Last Suffix Requesting Authority Unit Contact Phone Number

SECTION II: GUEST INFORMATION

First MI Last Suffix SSN Date of Birth Gender Height (In ft. & in) Weight

Current Home Address Street City State Zip Code

Driver’s License or Government ID No. or State ID No.

ID No. State

Expiration (MM/DD/YYYY) Ethnicity U.S. Citizen

Yes No

THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A

FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED

STATES CODE, SECTION 1001 OR OTHER APPLICABLE LAWS AND REGULATIONS.

NOTE: "REQUESTING AUTHORITY AND/OR GUEST" SHALL RETURN BADGE TO PASS AND ID OFFICE UPON EXPIRATION.

SECTION III: SIGNATURES

Requesting Authority Signature Date

Guest’s Signature Date

SECTION IV: REQUEST JUSTIFICATION

Describe in detail why the guest requires access to the installation. Your recommendation will be reviewed by the Pass & ID staff.

For Construction Project Requesting Authorities:

Project Name Project Expiration Date Requested Credential Expiration Date

SECTION V: TO BE COMPLETED BY 177TH SECURITY FORCES ONLY

Control No. Fitness Determination By:

CCH: Yes No Approved Disapproved

Date Credential Issued Date Expires Type of Credential

177 SFS Form 40, 20141211 V1 Previous edition is obsolete All signature blocks must be signed

Eye Color Hair Color

SSN or DOD ID