Attachment_6_Installation_Access_Request_Form.pdf

JBM-HH Form 190-16x, 16 May 18

Joint Base Myer-Henderson Hall (JBM-HH) Installa on Access Request For use of this form, see JBM-HH Reg 190-16, Proponent is Directorate of Emergency Services

Privacy Act Advisement: The informa on requested is for the purpose of gran ng access to the JBM-HH installa on. Providing requested informa on, to include your social security number (SSN), is voluntary. However, your access may not be granted if all requested informa on is not provided. Authori es: Execu ve Orders (EO) 10450, 10865, and 12333. The SSN, required for record accuracy, is requested pursuant to 10 U.S.C. 3013, Secretary of the Army; AR 190-13, The Army Physical Security Program, and EO 9397. Principal Purpose(s): The informa on collected on this form is used to screen and iden fy access applicants to JBM-HH who may have criminal histories or involvements which preclude installa on access. Completed forms are used to conduct background records checks for determina ons of the eligibility of applicants for access to JBM-HH.

Completed forms are covered by official SORNs. Disclosure: Voluntary. However, failure of the applicant to complete any of the applicant required sec ons may result in refusal of access to JBM-HH. An applicant’s SSN is used to conduct law enforcement records checks and Government data base queries. All informa on is “For Official Use Only” and will only be released to the JBM-HH Police Department or other authorized agency personnel for the purposes of determining access eligibility and/or enforcing Federal, state, local law or regula ons. Informa on retrieved from law enforcement records checks and Government data base queries will not be disclosed to the applicant IAW Na onal Crime Informa on Center and Interstate Iden fica on Index laws, user agreements, Army Direc ve 2014-05 and official guidance.

Sec on A. Visitor Applicant Informa on

Type of Applicant: (check appropriate box)

VISITOR CONTRACTOR OTHER ___________________

1. Name (last, first, middle ini al): 2. Date of Birth: 3. Gender:

Male

Female

4. Race:

5. Social Security Number: 6a. Driver’s License or State ID Number: 6c. U.S. or U.S Territory Passport Number (if state driver’s license or ID not available): 6b. Issuing State or Territory:

7. Residen al Address: (Include City/State/ZIP Code) 8. Home Phone Number: 9. Cellular Phone Number:

10. Are you a U.S. Ci zen?

Yes No

If you are a U.S. Ci zen, skip ques ons 10a thru 10d

10a. Do you have a Visa, Foreign Passport or Official Military Orders allowing travel, work or residency in the U.S.?

Yes No

Please indicate what documenta on you have and the corresponding alphanumeric number: ___________________________________________________

10d. Do you have a Foreign Na onal Number (FNN): Yes No

(If yes, list your FNN: __________________________________________________________________________)

10b. Work Authoriza on Card (aka; Employment Authoriza on Card): Form I-766 Permanent Resident Card (aka; Green Card): Form I-551

List the alphanumeric iden fier for your work authoriza on document: ________________________________________________________________________________

10c. Do you have a Alien Registra on Number (ARN): Yes No

(If yes, list your ARN: ______________________________________________________________________________________)

Note: If you are a non-U.S. ci zen, you must provide all relevant documenta on for verifica on. The visitor Control Center (VCC) is required to make and retain photocopies of all docu-menta on which allows you to work, reside or visit the U.S. for the purpose of installa on access.

Sec on B. Contractor/Vendor Informa on (If Applicable)

1. Contractor/Vendor Company Name: 2. Company Phone Number:

4. Contractor/Vendor Address: (Include City/State/ZIP Code) 5. Contractor/Vendor Company Point of Contact:

3. Contract Number: (if applicable)

6. Contractor/Vendor Applicant Category:

Place a check beside the descrip on which best describes your contract category.

CAC eligible Contractor Non-CAC eligible Contractor

7. Requested Dura on of Access:

(Not to exceed one year)

8. Contract Dates and Work to Be Performed:

11. Applicant Category: Please place a check beside the descrip on which best describes your category.

Non-DoD Affiliate Visitor Gold Start Family Member Foreign Military Member on Official Orders Taxi/Limo/Uber or Li Driver Foreign Na onal

Family Care Provider Employee of JBM-HH Resident Volunteer Tow Truck Driver Commercial Delivery Moving Company

Guest of JBM-HH Resident DRMWR Member Event A endee Thri Shop Other _____________________________________

12. Requested Dura on of Access: (not to exceed 1 year) Requested Date(s)/Time(s) of Visit

From Date: _______________________________________ To Date: _________________________________________

From Time: ________________________ To Time: ____________________________

13. Jus fica on for Pass:

JBM-HH Form 190-16x, 16 May 18

Sec on E. Background Verifica on

Security Force Use Only– Applicant Does Not Fill Out This Sec on

1. Type of NCIC-III Check Completed: VCIN WALES

Result: Derogatory Informa on Found No Derogatory Informa on Found

No Record Match

2. TSDB Check Completed: YES NO

Derogatory Informa on Found No Derogatory Informa on Found N/A

3. ALERTS Check Completed: YES NO

Derogatory Informa on Found No Derogatory Informa on Found N/A

4. Does a Waiver packet need to be provided to the applicant?

YES NO

5. If yes, was a Waiver packet provided to the applicant? YES NO

6. How was the waiver packet delivered to the applicant?

In Person Via email to the sponsor Other: ___________________ N/A

7. If a waiver packet was not provided to the applicant or sponsor, please explain why:

1. Printed Name: (last, first, middle ini al): 2. Signature: 3. Date: (month, day, year)

Sec on F. Pass Informa on

1. Type of Pass Issued: Approved Disapproved

24 Hour Visitor Pass 30 Day Visitor Pass 60 Day Visitor Pass 90 Day Visitor Pass 6 Month Visitor Card 1 Year Visitor Card

Other (explain type of pass and length): ___________________________________________________________________

Validity Date Range of Pass: From ___________________________________ To ______________________________________

Sec on G. Security Force Conduc ng Check and Issuing Pass Informa on

Disposi on: This informa on will be retained and kept on file for two years.

Sec on D. Sponsor Informa on

1. Name (last, first, middle ini al): 2. Grade/Rank/Status: 3. Date of Birth: 4. Gender:

Male Female

5a. Driver’s License or State ID Number: 5b. Issuing State or Territory: 5c. U.S. or U.S Territory Passport Number (if state driver’s license or ID not available): 6. Work Phone:

7. Organiza on/Unit (for Ac ve Duty or Civilian DoD Employees Only): 8. Government Email:

11. Sponsor’s Cer fica on:

I cer fy that the applicant meets the jus fica on requirements as indicated in JBM- HH Regula on 190-16, Access Control Policy, for access privileges. Furthermore, I cer fy that the applicant requires a Visitor Pass as indicated above in order to per-form assigned du es, conduct official business or has valid purpose for JBBMH-HH access.

11a. Sponsor’s Signature: (invalid if incomplete)

9. Are you the COR or CoTR:

Yes No

10. If you are not the COR or CoTR, list the name, telephone number and email of the COR or CoTR:

Name: _______________________________________________________________ Phone: _____________________________________ Email: _______________________________________________________

2. Applicant’s Signature:

The data retrieved for installa on access ve ng is “For Official Use Only” and will be maintained and used in strict confidence in accordance with Federal, state, local laws and regula ons.

Personnel record screening, u lizing the Na onal Crime Informa on Center and Interstate Iden fica on Index (NCIC-III), the Virginia Criminal Informa on Network (VCIN), the Washington Area Law Enforcement System (WALES), the Terrorist Screening Data Base (TSDB), Army Law Enforcement Repor ng and Tracking System (ALERTS) and Installa on Debarment Lists, is a voluntary process. Applicants reques ng JBM-HH access are not required to submit to personal record screening; however person(s) who elect not to authorize the personnel record screening and ve ng process will not be granted access to JBM-HH whether escorted or unescorted.

By signing below the applicant asserts the following:

-I cer fy that, to the best of my knowledge and belief, all of the informa on on and a ached to this request for JBM-HH Installa on Access Control Pass request, including any a ached applica on materials, is true, correct, complete, and made in good faith.

-I understand that a false or fraudulent answer to any ques on or item on any part of this applica on or its a achments may be grounds for the denial of installa on access.

-I understand that any informa on I give may be verified and/or examined for the purpose of determining eligibility for JBM-HH installa on access and/or the execu on of Federal, state, local laws and regula ons.

-I consent to the release of informa on about my criminal history from law enforcement or criminal jus ce agencies, law enforcement state or federal data bases, criminal history record informa on, federal installa ons or proper es and other authorized employees or representa ves of the Federal Government.

-I understand that my consent is voluntary and I may refuse to give my consent.

-I understand I have the right to refuse authorized representa ves of JBM-HH to obtain my criminal history.

I understand that derogatory results of any such inquiries may result in the denial of installa on access and/or the execu on of an outstanding legal service or warrant from informa on obtained through authorita ve law enforcement data bases.

-I understand that informa on released by records custodians and sources of informa on is for the official use by the Federal Government only for purposes provided in this form, and may be redisclosed by the Government only as authorized by law. Copies of this authoriza on that show my signature are as valid as the original release signed by me.

-I assert I understand all of the informa on stated herein and have requested clarifica on or explana on of any terms, concepts or procedures which were unclear to me.

-I hereby consent to have my name and provided iden fying informa on ve ed u lizing any or all of the following systems: NCIC -III, VCIN, WALES, the TSDB and ALERTS.

Sec on C. Authoriza on For Criminal Records Release

1. Applicant’s Printed Name (last, first, middle ini al): 3. Date: (month, day, year)