Attachment 3 IMDR-ES Form 2 Application for Sponsorship.pdf

IMDR-ES FORM 2, JAN 2016 PREVIOUS EDITION IS OBSOLETE

APPLICATION FOR SPONSORSHIP

PRIVACY ACT STATEMENT: The information you provide is covered by the Privacy Act of 1974, Title 5, U.S.C. 552a.

AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; Army Regulation 190-13, The Army Physical Security Program and E.O. 9397 (SSN).

PRINCIPAL PURPOSE(S): To record personal data and vehicle information to ensure positive identification of personnel authorized access to the installation/restricted areas; to conduct criminal background checks through local and national law enforcement databases; to maintain accountability for issuance and disposition of access passes.

ROUTINE USES: The DoD Blanket Routine Use set forth at the beginning of the Army's compilation of systems of records notices may apply to this system.

DISCLOSURE: Voluntary. However, failure to provide the requested information will result in denial of access to the installation.

Request sponsorship for the following individuals:

Last Name

First Name

Middle Initial

Date of Birth

ID Type

ID Number

ID State *See Reverse*

Vehicle Make

Vehicle Color

Vehicle Plate

State

Relationship

Justification:

DATE OF REQUESTED ACCESS (MM/DD/YYYY) TIME OF REQUESTED ACCESS

FROM TO FROM TO

DAYS REQUESTED ACCESS MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

SPONSOR’S INFORMATION:

LAST NAME: _ _ _ FIRST NAME: MI:

RANK/GRADE: __ ORGANIZATION: _ _ TELE:

ADDRESS: _ _ EMAIL: _ _

I acknowledge as a Sponsor that the name(d) individuals have official business to conduct on Fort Drum

(Sponsor’s Signature) Date

The above individuals are approved / disapproved for issuance of Friends of the North Country Local Access Badge.

Approving Official Printed Name Approving Official Signature

SECTION BELOW IS FOR USE BY INSTALLATION ACCESS CONTROL OFFICE

NCIC-III DATE: CLEARED / FAILED (circle one) CONTROL #

NCIC-III Officer Printed Name NCIC-III Officer Signature

IMDR-ES FORM 2, JAN 2016 PREVIOUS EDITION IS OBSOLETE

APPLICATION FOR SPONSORSHIP INSTRUCTIONS

USE: The information contained in the application will serve as input data to conduct a NCIC-III background check as required by AR 190-13. If you do not type the information on this form insure that your writing is neat and legible to avoid any mistakes, confusion, or delays when conducting checks and preparing passes.It is essential that all users of this form provide the required information according to the instructions below:

Last Name: self-explanatory.

First Name: self-explanatory.

Middle Initial: self-explanatory.

Date of Birth: DDMMMYYYY (example: 05 Feb 1965)

ID Type: Driver’s License; Passport; School ID; etc.

ID Number: may be letters and numbers depending on identification.

ID State: State that issued ID. DoD, like all other Federal agencies is prohibited from accepting non-compliant DL, therefore visitor control centers will no longer accept a non-REAL ID driver’s license or identification card for physical access from Illinois, Minnesota, Missouri, and Washington. Therefore, unless the individual possesses one of the following authorized government issued identification cards, they will not be granted unescorted access on Fort Drum: U.S. passport, permanent resident card / alien registration receipt card, employment authorization document with photo, school identification card with photo, U.S. Military or draft record, U.S. Coast Guard Merchant Mariner Cards, Transportation Worker Identification Card, Native American Tribal Document.

Vehicle Make: Ford, Chevy, Toyota, etc.

Vehicle Color: Red, Blue, Black, White, etc.

Vehicle Plate: The alphanumeric license plate displayed on the vehicle.

State: The state that issued the plate displayed on the vehicle.

Relationship: The connection between the individual being sponsored and the sponsor (mother, father, son, daughter, friend, contractor, etc.)

Justification: Explain the reason (bonafide need) why the individual(s) need access to Fort Drum.

Dates of Requested Access: DDMMMYYYY (example: 05 Feb 1965) for From and To.

Times of Requested Access: 24 hour clock (1300; 2315; etc.) for From and To.

Days Requested Access: Check the box for each applicable day of the week.

Sponsor’s Information: self-explanatory.

Sponsor’s Signature and date: self-explanatory. Electronic signature preferred.

The completed form can be emailed to:

usarmy.drum.imcom-atlantic.mbx.des-acp@mail.mil (Preferred method)

Faxed to 315-772-9173 or

Delivered to Room 223, 2nd Floor, MP Station, 10715 Mt Belvedere Blvd mailto:usarmy.drum.imcom-atlantic.mbx.des-acp@mail.mil