Attachment 0006 Visitor Request 2025.pdf

LETTERKENNY ARMY DEPOT ACCESS CONTROL APPLICATION

AMLD FORM 4497 (OCT 2025)

Applicant's Name (Last, First Mi):

Information on this form will be used to facilitate the completion of a National Crime Information Center (NCIC) III criminal background check IAW AR 190-13

Maiden:

Full SSN:

Height: Weight: Sex: Race: Hair:Eye:

Full Home Address:

Employer/Business:

Driver's License # and State:

DOB: Citizenship:

Phone Number:

I have read and verified to the best of my ability that all of the information listed above is correct.

I understand that providing false or incorrect information on this form may affect my eligibility for access to the installation.

Applicant's Signature: Date:

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. Section 3013, Secretary of the Army; AR 600-20, Army Command Policy and E.O. 9397 (SSN). DoD Directive (DoDD) 5200.27 and the authority in DoDD 5106.01.PRINCIPAL PURPOSE(s): Prescribes procedures for DoD law enforcement activities

(LEAs) to request, collect, maintain, use, and disseminate personally identifiable information (PII) and law enforcement information from person

(s) during routine security and law enforcement functions (e.g., crime prevention, force protection, and criminal investigations). ROUTINE USE

(S): DoD LEAs may collect, use, maintain, and disseminate PII and law enforcement information in compliance with section 552a of title 5, United States Code (also known as “The Privacy Act of 1974”), implemented in the DoD by DoDD 5400.11 and DoD 5400.11-R.

DISCLOSURE: Voluntary. However, failure to provide all the requested information could lead to delay or rejection of entry onto the installation, or delay in completion or processing of requested or required documents for inadequate data.

Is your Driver's License currently under suspension? Yes No

Purpose of Visit:Date of Visit:

Sponsor's Name: Sponsor's Agency:

Sponsor's Email: Sponsor's Telephone:

LETTERKENNY ARMY DEPOT ACCESS CONTROL APPLICATION

AMLD FORM 4497 (OCT 2025)

Information on this form will be used to facilitate the completion of a National Crime Information Center (NCIC) III criminal background check IAW AR 190-13 I have read and verified to the best of my ability that all of the information listed above is correct.

I understand that providing false or incorrect information on this form may affect my eligibility for access to the installation.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. Section 3013, Secretary of the Army; AR 600-20, Army Command Policy and E.O. 9397 (SSN). DoD Directive (DoDD) 5200.27 and the authority in DoDD 5106.01.PRINCIPAL PURPOSE(s): Prescribes procedures for DoD law enforcement activities (LEAs) to request, collect, maintain, use, and disseminate personally identifiable information (PII) and law enforcement information from person(s) during routine security and law enforcement functions (e.g., crime prevention, force protection, and criminal investigations). ROUTINE USE(S): DoD LEAs may collect, use, maintain, and disseminate PII and law enforcement information in compliance with section 552a of title 5, United States Code (also known as “The Privacy Act of 1974”), implemented in the DoD by DoDD 5400.11 and DoD 5400.11-R. DISCLOSURE: Voluntary. However, failure to provide all the requested information could lead to delay or rejection of entry onto the installation, or delay in completion or processing of requested or required documents for inadequate data.

Is your Driver's License currently under suspension?

9.0.0.2.20120627.2.874785