Attachment 11 - CURRENT SFS 30.pdf

b

CONTROLLED UNCLASSIFIED INFORMATION

MEMORANDUM FOR 366 SFS S3OV

FROM:

SUBJECT: Request for Installation Entry Pass (366 SFS Form 30)

1. The following individual is requesting issuance of a Base Access Pass for the reason / time period listed.

This letter is submitted IAW the 366 FW/Installation Defense Instruction.

TYPE OR FILL OUT LEGIBLY OR APPLICATION WILL NOT BE PROCESSED

APPLICATION MUST BE FILED TWO WEEKS IN ADVANCE OF NEEDING BASE ACCESS

1. FULL LEGAL NAME ( FIRST, MIDDLE , LAST)

3. SSAN 4. DATE OF BIRTH (YYYY/MM/DD)

5. D/L NUMBER (OR PASSPORT NUMBER) 6. STATE 7. CONTRACT NO. REQ'D FOR 1 YEAR PASSES

8. CONTRACT DATES / DATES OF VISIT 9. DUTY HOURS 10. DAYS REQUIRED (i.e. M/W/F)

Su M Tu W Th F Sa

11. EMPLOYED BY AND SPONSORS NAME & EMAIL ADDRESS 12. ON BASE SPONSOR PHONE #

2. Does the contractor require access to classified material: NO YES

3. Individual listed has been informed that a background and local files check will be conducted. The individual has been informed that disclosure of the above information is voluntary; however, failure to do so could result in the individual being denied access to the installation.

1st Ind, 366 SF /S3OV

MEMORANDUM FOR:

Approved/Disapproved

I

A

S

L

X

Authenticated on by

(Date)

(Signature)

(Printed name & grade) 366 SFS/S3OV

PRIVACY ACT STATEMENT: Authority: 50 U.S.C 797 and DOD Directive 5400 B

PRINCIPAL PURPOSES: To identify personnel requesting unescorted entry on to MHAFB who are Official Business Guests/

Students/Visitors/Houseguests/Designated Agents/MHSD Employees/FW-CC Sponsored Guests. ROUTINE USES: Information will be used to conduct a wants and warrants, criminal history check through the Air Force Law Enforcement Terminal System (AFLETS) and the local files check at the security police reports and analysis section (366 FW/A7SR).

DISCLOSURE IS VOLUNTARY: Failure to provide the information could result in the individual being denied base access. This letter of request will be sent to 366 SFS S3OV two weeks prior to the date the individual concerned requires the pass. 366 SFS FORM 30, Dec 2012

DISPOSITION: This document is for official use only once completed; if this document is no longer in use shred it for protection of the contents.

CONTROLLED UNCLASSIFIED INFORMATION

Male / Female

Agency/Duty Title/ Phone#