Attachment 4 DARB 4 Access Request Form.pdf

DARB 4 - DOBBINS SECURITY FORCES PRE-AUTHORIZATION

GROUP (3 OR MORE PEOPLE)/SPECIAL EVENT

ACCESS REQUEST FORM

Authenticated by Name, Rank/Grade:

Date:

Pages Signature:

Time:

of

Distribution: Police Services, Pass & ID, Gate 1, Gate 2, BDOC

Privacy Act - 1974 as Amended Applies--This communication may contain information which must be protected IAW DoD 5400.11R, AFI 33-119, AFI 33-129 and is "FOR OFFICIAL USE ONLY (FOUO)"

Version 20130614

1. Sponsor Register in DBIDS: YES NO Note: All DoD ID Cardholders must be registered in DBIDS to sponsor a group of visitors/guest on Dobbins.

2.Effective Date/Time of Visit:

3. Sponsor/Escort Full Name: 4. Expiration Time of Visit: Expiration Date of Visit:

5. Reason for Access: 6. Sponsor/Escort Contact Number Work: Cell:

7. Location (building/s or area to be occupied) at Dobbins

8. Special Notes

9. The individuals listed are a visitor/guest of: . I take full responsibility for the individuals and to the extent of my knowledge, these guests/visitors are trustworthy and reliable and do not possess any adverse character traits or exhibit any indications of aberrant behavior that would constitute an unreasonable risk to the health and safety of members assigned and working on Dobbins Air Reserve Base. I, therefore request that these guests/visitors be granted clearance for access to the installation upon satisfactory completion of their required criminal history/background check. I have briefed the listed individuals of the entry procedures required to enter DARB. My guests understand that upon entering the facility they may be required to submit to an installation entry point check. The driver must have a valid driver's license, proof of vehicle auto insurance, proof of vehicle registration and must abide by all base traffic instructions. Passengers must have valid photo identification. The use of seatbelts is mandatory on Dobbins ARB.

10. SIGNATURE: 11. DATE:

12. DRIVER’S LICENSE NUMBER:

13. STATE ISSUED:

14. SPONSOR’S DATE OF BIRTH:

15. SPONSOR’S SOCIAL SECURITY NUMBER (LAST 4):

Please note: The sponsor is required to complete the form and must either fax to: 678 655-5999 or hand deliver to the Pass & Registration Office, Bldg 866. Email submissions cannot and will not be accepted due to the Information Assurance policy. Also, if the sponsor is not registered in DBIDS at the time of submission, the request for access will not be accepted.

Privacy Act - 1974 as Amended Applies--This communication may contain information which must be protected IAW DoD 5400.11R, AFI 33-119, AFI 33-129 and is "FOR OFFICIAL USE ONLY (FOUO)"

Version 20130614

NOTE: Non-US citizens require 15 calendar days for proper vetting prior to entry.

16.Type Visitor:

(Please check one) Personal Visitor Business Visitor Vendor/Service Worker

17.Date of Request:

18. Sponsor Organization:

19. Sponsor Name:

20. Time and Date/s of visit:

21. Title of Event 22. Sponsor Contact Number ( Cell phone # preferred ):

23. Last Name, First, MI 24. Citizenship 25. Date of Birth 26. Driver's License Number

27. Drivers's License State of Issue

1.EXAMPLE: SMITH, JOHN D. U.S 12/25/1960 1234578 GA

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