ATTACHMENT 4 - Base Entry Request.pdf

Authorized Unescorted Base Entry Request

PRIVACY ACT STATEMENT

AUTHORITY: AFMAN 31-113, Para. 1.3.1.

PRINCIPLE PURPOSE: Collection of information to identity proof and vet for unescorted base entry. All information is for unescorted base entry purposes only.

ROUTINE USE: Local Law Enforcement DISCLOSURE IS VOLUNTARY: Disclosing Personally Identifiable Information (PII) is completely voluntary. However, failure to provide the requested information may prevent, and/or cause a delay regarding a request.

FOR OFFICIAL USE ONLY. Once Completed this document contains Personally Identifiable and For Official Use Only (FOUO) information which must be protected under the Privacy Act and AFI 33-332.

1. NAME: (Last, First, Middle Initial) 2. DRIVER’S LICENSE NUMBER: 3. STATE:

DATE : mm/dd/yyyy

4.TELEPHONE NUMBER: Include Area code

8. SPONSOR NAME: (Last, First, Middle Initial)

11. SPONSOR DATE OF BIRTH: 12. PRIMARY TELEPHONE NUMBER: 13. SECONDARY TELEPHONE NUMBER:

9. SPONSOR UNIT/OFFICE SYMBOL:

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10. RANK:

14. REASON FOR THE REQUEST:

NOTE: Request expires at 1600 on the "to" date

SECTION I: Requestee Information - continue on page 2 as required

SECTION II: Sponsor Information

7. DATE(S) OF REQUEST: FROM: TO:

SECTION III: Request Information

I agree to take full responsibility for those individual(s) that I have requested unescorted entry for. I have verified a valid reason for entry. I have briefed the visitors listed above that the possession of illegal drugs or substances will result in prosecution, and that no weapons are allowed onto the installation. Weapons restrictions apply to CCW holders as well as State certified police officers unless on official duty. If the individuals listed above no longer require access prior to expiration I will notify the 178th SFS/S5R office 937-327-2528.

15. SIGNATURE OF SPONSOR:

For additional information, contact the 178 Wing SFS/S5R office at DSN 346-2528, Commercial Telephone at 937-327-2528 or by e-mail at usaf.oh.178-wg.mbx.sfs-visitor-mailbox@mail.mil .

SECTION IV: Declaration of Responsibility

5. DATE OF BIRTH NOTE: Social Security Number use is only 6. SOCIAL SECURITY NUMBER authorized for persons without a drivers license or when asked for by SFS for further clarification. Any other use may constitute a Privacy Act Breach resulting in UCMJ action &/or civil litigation.

Authorized Unescorted Base Entry Request

1a. NAME: (Last, First, Middle Initial) 2a. DRIVER’S LICENSE NUMBER: 3a. STATE:

4a. PRIMARY TELEPHONE NUMBER: Include Area code

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Requestee Information - Continued from Section 1 page 1

5a. DATE OF BIRTH (Out of State only) 6a. SSN (Out of State only)