Attachment 0009 - Rock Island Arsenal Access Request Form.pdf

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ROCK ISLAND ARSENAL ACCESS REQUEST FORM

Visitors are Welcome to RIA

SECTION I - PERSONAL INFORMATION

NAME (Last, First, Middle Name)

LAST FOUR OF SOCIAL SECURITY #

DATE OF BIRTH (Month/Day/Year)

HOME ADDRESS/NUMBER AND STREET:

CITY

STATE

ZIP CODE

SECTION II - PURPOSE OF VISIT

OFFICIAL/COMMERICAL BUSINESS:

RECREATIONAL VISIT:

GOVERNMENT POINT CONTACT NAME:

FIRST ARMY

ASC

CHRA/CPAC

COMMISSARY/PX

CONTRACTING

CREDIT UNION

JMC

JMTC

FISHING

Quarters 1 COL Davenport House Arsenal Attic

MWR EVENT

MUSEUM

LOCK & DAM VISITOR CENTER

HISTORIC SITES

OTHER

PHONE:

Purpose: The United States Army requires a criminal records check be conducted on all visitors not affiliated with the Department of Defense or US Government.

ARMY CORPS OF ENGINEERS

GYM

GARRISON

RESERVE CENTER

CEMETERY

RIA FORM 190-1, FEBRUARY 2021

RACE

SEX

F Y N

U.S. CITIZEN

M

PLACE OF BIRTH:

PHONE:

DES COMPLETE

Date Length Family Housing New Hire Rideshare (ie: uber, taxi) SECTION III (For Official/Commercial Business Only)

SECTION IV PRIVACY ACT STATEMENT

I HEREBY CONSENT TO THE RELEASE OF MY CRIMINAL HISTORY RECORDS.

I Authorize a representative of the Rock Island Arsenal, Directorate of Emergency Services to conduct my background check, to obtain any information relating to my criminal history record. I authorize the Rock Island Arsenal Police Department, conducting my investigation to disclose the record of my background investigation to the official responsible for making a determination of suitability or eligibility for access to Rock Island Arsenal. I understand that the information released by records custodians and sources of information is for OFFICIAL USE ONLY by the Rock Island Arsenal for the purposes stated and that it may be re-disclosed by the government only as authorized by law. I further understand that with the signing of this form I authorize additional background checks as may be needed by representatives of the Rock Island Arsenal for continuing access to the installation.

My information on this form is true, complete, and correct to the best of my knowledge.

SIGNATURE OF APPLICANT

DATE

Delivery/Pick-up

COMPANY NAME:

PHONE:

This form must be completed and submitted to the visitor control center via email: usarmy.ria.imcom.mbx-usag-access-request.mil from a (.mil) address or bring this in person with you.

Visitor Control Center FAX: 309-782-5029 Building # 23 Phone: 309-782-1337 Rock Island Arsenal Email: usarmy.ria.imcom.mbx.usag-access-request@mail.mil Rock Island, IL 61299-5000 Bring this form in person with you.

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