ATTACHMENT 4 - 152 AW Access Request - W50S8C-20-B-0001 - YYYY MM DD.pdf

State:

SECURITY FORCES USE ONLY

Military Point of Contact:

(Rank, Last Name, First Name) Military Point of Contacts Phone Number:

BY SIGNING BELOW, YOU CERTIFY THAT YOU HAVE READ AND UNDERSTAND THE ACCESS REQUIREMENTS; HAVE PROVIDED THE MOST ACCURATE AND CORRECT INFORMATION POSSIBLE; AND AGREE TO HAVE THE 152ND SECURITY FORCES SQUADRON CONDUCT A

BACKGROUND CHECK TO VERIFY ACCESS ELIGIBILITY.

Signature: Date:

Project/Contract Name:

(Provide Description if possible)

Employer(s): Employer Phone Number:

Solicitation Number:

(If Provided)

First Day of Access:

(Can Be Estimated)

Last Day of Access:

(Can Be Estimated)

Justification and Access Information

Phone Number: Date of Birth:

City of Birth: County of Birth: State of Birth:

Social Security Number:

(Full)

Drivers License or Identification Card Information

Number:

Current Address:

City: State: Zip Code:

Nevada Air National Guard ‐ Individual Access Request

FOR OFFICIAL USE ONLY

Authority: 10 U.S.C. 8013; 44 U.S.C. 3101

Purpose: This form requires collecting and maintaining information protected by the Privacy Act of 1974. Form will be safeguarded from unauthorized disclosure. Routine Uses:

152 Security Forces Squadron uses the information to determine suitability to enter the NVANG installation

Failure to include all requested information may result in denial of access to the installation.

To be a PoC/Escort, you must be a NVANG member, Dependent, or Retiree. PoC/Escort is responsible for all visitors and their actions while on the installation. PoC/Escort is responsible to notify visitors that are not granted access.

Wing CC or their designee must approve all events/visits prior to submitting Visitor List to Security Forces. All persons over the age of 16 MUST possess a Current & Valid US

Government or State Issued Photo ID.

All drivers must have in their possession a valid State (any) Driver’s License, Valid Vehicle Registration and Current Proof of Insurance. Furthermore, all drivers must adhere to base driving policies (15mph Speed Limit, 100% Seatbelts, hands‐free cellular devices only).

NO WEAPONS OF ANY KIND ALLOWED ON BASE.

Any non‐military guests may be subject to a criminal history background check in order to ensure the following base entry criteria is met: Verify Identity, No Warrants, Not

Barred From Any Federal Property, No Convictions of Sexual Assault/Rape/etc., Armed Robbery, Trafficking in Humans, Drug Possession with Intent to Sell or Distribute, any

Firearm or Explosive related Felony, or any Felony (not previously listed) within the last 10 years.

Security Forces maintains the right to bar or remove any individual(s) that present a threat to the safety or security of the base, its members or guests.

Completed form must be submitted NLT 7 days prior to event to usaf.nv.152‐aw.list.pass‐id@mail.mil

Personal Information

Last Name: First Name: Middle Initial: