Attachment 0008 - T.E. #4 Automated Installation Entry (AIE) Application AIE Application.pdf

Sex:

Eye Color:

Start: End:

NCIC Checked By: Date:

Applicant Info Authenticated By:

IPC Community Center Manager Signature:

IP

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IPC Community Center Manager Contact Number:

Housing Comments:

IPC Community Center Manager Print Name:

Applicant Information

DD/MM/YYYY

SSN:

Phone #:

House Number / Street Name / Apt. Number Duration of Pass:

Home Address:

PRIVACY ACT INFORMATION

Disclosure: Submitting requested information is voluntary, however failure to provide information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the Common Access Pass (CAP).

Routine Use: Information provided may be used to determine suitability of applicants desiring access on to U.S. Army Garrison, Hawaii Installations as well as for other lawful purposes including law enforcement and litigation. For other official purposes, information on this form may be provided to other law enforcement agencies.

Principal Purpose: The purpose for requesting personal information is to assist civilian access on to U.S. Army Garrison, Hawaii Installations.

Authority: Title 10, United States Code, Section 2012

STATEMENT OF UNDERSTANDING: BY SIGNING THIS APPLICATION FOR A COMMON ACCESS PASS (CAP) ID CARD, I AGREE TO ABIDE BY ARMY REGULATIONS WHILE ON U.S. ARMY GARRISON, HAWAII

INSTALLATIONS. I ALSO CERTIFY THAT ALL INFORMATION PROVIDED ON THIS FORM IS TRUE AND CORRECT.

Applicant's Signature:

AUTHORIZATION: HOMELAND SECURITY PRESIDENTIAL DIRECTIVE 12 AND ARMY REGULATION 190-13 REQUIRES THAT ANY PERSON NOT POSSESSING A GOVERNMENT ISSUED IDENTIFICATION AND

WISHING TO BE GRANTED ACCESS TO A FEDERAL FACILITY BE VETTED USING THE NATIONAL CRIME INFORMATION CENTER (NCIC). The following issues will prevent access to USAG-HI installations:

Current Arrest Warrant, Currently Barred from entry to Federal Installations, Any felonies within the last 10 years, Registered Sex Offenders, Crimes encompassing Sexual Assault, Armed Robbery, Rape, Child Molestation, production or possession of Child Pornography, Trafficking in Humans, Drug Possession with intent to sell or Drug Distribution, Espionage, Sabotage, Treason, Terrorism, Murder, Firearms/Explosive violation, or Acts or

Activities designed to overthrow the U.S. Government by force. USAG-HI can add further disqualifying factors that would deny an individual access onto its installations.

Date:

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Check all that apply:

Request the following individual be authorized a U.S. Army Garrison Hawaii VCC Common Access Pass (CAP).

Only E-6 and below requires a Unit Commander's Signature

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Date:

Commander's Name:

Date:Commander's Signature:

Sponsor's Address:

Sponsor's Signature: Date:

Duty Phone:Rank / Grade:

STATEMENT OF UNDERSTANDING: I UNDERSTAND THAT AS THE SPONSOR, I AM RESPONSIBLE FOR THE ACTIONS OF THE ABOVE NAMED INDIVIDUAL. REPORTS OF MISCONDUCT MAY BE

CAUSE FOR IMMEDIATE TERMINATION OF THIS AUTHORIZATION. I ALSO UNDERSTAND THAT IF THE PASS IS NO LONGER NEEDED AND HAS NOT EXPIRED, I WILL RETRIEVE THE PASS AND

TURN IT OVER TO THE INSTALLATION ACCESS PASS OFFICE.

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Sponsor Name: Rank / Grade:

City Zip Code DD/MM/YYYY

Applicant Name:

USAG-HI Automated Installation Entry (AIE) Application

Duty Phone: HomePhone:

Weight:

City / State / Country of Birth:

Relationship to Sponsor:

Date of Birth: Hair Color: Height:

To:Visitor Control Center 199 Leilehua Golf course Road, Bldg 6508, Wahiawa VCC Office Phone: (808) 655-1620/ Present: Valid Drivers License or State ID

Sponsor SSN:

NO DRIVING ON

POST

DENIEDedAPPROVED

PARENTS OF CHILDREN(SCHOOLS ON POST)

HOUSEGUEST

CAREGIVER

VISITOR

Base:

Days: Hours:

T.E.#4 Attachment A

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Applicant Information

Sex:

Eye Color:

Start: End:

Applicant Name:

Passport #:

USAG-HI Automated Installation Entry (AIE) Application for Foreign Visitors ONE APPLICATION PER SPONSOR (not to exceed travel itinerary's length of stay)

To: Garrison Commander's Office via the Visitor Control Center

Duty Phone: HomePhone:

Weight:

City / Country of Birth:

Relationship to Sponsor:

Date of Birth: Hair Color: Height:

VCC Office Phone: (808) 655-1620

Sponsor SSN:

STATEMENT OF UNDERSTANDING: I UNDERSTAND THAT AS THE SPONSOR, I AM RESPONSIBLE FOR THE ACTIONS OF THE ABOVE NAMED INDIVIDUAL. REPORTS OF MISCONDUCT MAY BE

CAUSE FOR IMMEDIATE TERMINATION OF THIS AUTHORIZATION. I ALSO UNDERSTAND THAT IF THE PASS IS NO LONGER NEEDED AND HAS NOT EXPIRED, I WILL RETRIEVE THE PASS AND

TURN IT OVER TO THE INSTALLATION ACCESS PASS OFFICE.

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Sponsor Name: Rank / Grade:

City, Country City Code / Zip Code

Request the following individual be authorized a U.S. Army Garrison Hawaii AIE Pass.

Only E-6 and below requires a Unit Commander's Signature

S P

O N

S O

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N F

O R

M A

T

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N

Date:

Commander's Name:

Date:Commander's Signature:

Sponsor's Address:

Sponsor's Signature: Date:

Duty Phone:Rank / Grade:

PRIVACY ACT INFORMATION

Disclosure: Submitting requested information is voluntary, however failure to provide information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the Common Access Pass (CAP).

Routine Use: Information provided may be used to determine suitability of applicants desiring access on to U.S. Army Garrison, Hawaii Installations as well as for other lawful purposes including law enforcement and litigation. For other official purposes, information on this form may be provided to other law enforcement agencies.

Principal Purpose: The purpose for requesting personal information is to assist civilian access on to U.S. Army Garrison, Hawaii Installations.

Authority: Title 10, United States Code, Section 2012

STATEMENT OF UNDERSTANDING: BY SIGNING THIS APPLICATION FOR AN AIE ACCESS PASS, I AGREE TO ABIDE BY ARMY REGULATIONS WHILE ON U.S. ARMY GARRISON, HAWAII

INSTALLATIONS. I ALSO CERTIFY THAT ALL INFORMATION PROVIDED ON THIS FORM IS TRUE AND CORRECT.

Applicant's Signature:

AUTHORIZATION: HOMELAND SECURITY PRESIDENTIAL DIRECTIVE 12 AND ARMY REGULATION 190-13 REQUIRES THAT ANY PERSON NOT POSSESSING A GOVERNMENT ISSUED IDENTIFICATION

AND WISHING TO BE GRANTED ACCESS TO A FEDERAL FACILITY BE VETTED USING THE NATIONAL CRIME INFORMATION CENTER (NCIC). The following issues will prevent access to USAG-HI installations: Current Arrest Warrant, Currently Barred from entry to Federal Installations, Any felonies within the last 10 years, Registered Sex Offenders, Crimes encompassing Sexual Assault, Armed Robbery, Rape, Child Molestation, production or possession of Child Pornography, Trafficking in Humans, Drug Possession with intent to sell or Drug Distribution, Espionage, Sabotage, Treason, Terrorism, Murder, Firearms/Explosive violation, or Acts or Activities designed to overthrow the U.S. Government by force. USAG-HI can add further disqualifying factors that would deny an individual access onto its installations.

If itinerary is not attached, please provide reason why:

Reason for un-escorted access request:

The issued AIE Badge is not to exceed the duration of the requestor's visit to the island of Oahu, Hawaii. Travel itinerary must be attached to this form for approval. Each requestor must provide a copy of their travel itinerary.

Travel itinerary attached:

DD/MM/YYYY DD/MM/YYYY

Country:

Phone #:

House Number / Street Name / Apt. Number Duration of Pass:

Home Address:

The AIE Application for Foreign Visitors is approved by the Garrison Commander on a case-by-case basis.

G a rr is o n C o m m a n d e rs

U s e O n ly Issue Date:

NCIC-III

Date:

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Check all that apply:

Control #

Expiration Date:

Garrison Commander's Signature:

Garrison Commander's Name:

APPROVED

DENIEDED

APPROVED DENIEDedAPPROVED

T.E.#4 Attachment B

DENIED

COUNTER-INTELLIGENCE (CI)

Date:Name: Name:

INSTALLATION ACCESS PASS APPLICATION FOR PERSONNEL

WORKING UNDER U.S. ARMY CONTRACT

(INSTRUCTIONS)

1. Sponsoring Organization: Fill out and verify all information to include SSAN. Submit application with original signatures, a paper and electronic copy of spreadsheet to Installation Access Pass Office. Any incomplete information will stop processing for entire application.

2. At time of processing applicant must show a valid driver’s or other official photo identification.

THRU:

TO: Installation Access Pass Office

FROM:

CONTRACT NUMBER EXPIRATION DATE TYPE WORK DAYS/HOURS WORKED INSTALLATION

The individuals on the attached spreadsheet are approved for the Contractor Installation Access Pass.

Number of Names Submitted =

COMMENTS:

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.

SPONSORING ORGANIZATION: ______________________________ PHONE NUMBER: _________________ DATE: _______________

SPONSOR NAME: ________________________________________ ________________________________________ (Print Name) (Signature)

APPROVING OFFICER: ________________________________________ ________________________________________ (Print Name) (Signature)

ISSUING OFFICAL: ___________________________________ _____________________________________ DATE: _______________ (Print Name) (Signature)

PRIVACY ACT STATEMENT

AUTHORITY: Section 3101, Title 44, United States Code, USC 552A PRINCIPAL PURPOSE: The purpose for requesting personal information is to assist security personnel in developing records to document contractor employee suitability for access to USARHAW installations, to work under U.S. Army contracts. The Social Security Number (SSN) is necessary to identify the person and records.

ROUTINE USES: This information may be used to determine suitability of persons desiring access to USARHAW installations as well as for other lawful purposes including law enforcement and litigation.

WHETHER DISCLOSER IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: Disclosure of requested information is mandatory. Failure to provide information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the U.S. Army contract while serving in the capacity of prime contractor or subcontractor/supplier, and employee.

T.E.#4 Attachment C