Attachment 7- POM Form 7.pdf
PDF 3 MB Posted
- Solicitation number
- W91QF426BA010
About this file
This is an Application for Installation Access form (POM Form 7, October 2015) for the U.S. Army Garrison, Presidio of Monterey, California, restricted to U.S. citizen applicants only.
The form requires sponsors to submit applications for personnel seeking installation access to the Presidio of Monterey. Section I collects sponsor information including name, work phone, organization, date of birth, full Social Security Number (for Defense Enrollment Eligibility Reporting System verification), contract expiration date for contractors, type of request (DBIDS Card or Access Roster), and purpose of visit (Mission Requirement or Other). Section II collects applicant information for up to eight individuals, including last name, first name, middle initial, driver's license number and issuing state, last four digits of Social Security Number, date of birth, requested access dates with specific date ranges, and days and times of access required (Monday through Sunday, with from/to times). The form authorizes criminal background checks via the National Crime Information Center Interstate Identification Index (NCIC III) using the Department of Defense database. Sponsors must submit completed forms encrypted via government email to the designated installation access mailbox. Law enforcement and approving authority sections on page two document the NCIC III check date, disqualifying factors determination (yes/no), and approval/disapproval decision with authorized signature and date. Authority derives from Public Law 110-181, the 2008 National Defense Authorization Act, Section 109, and U.S. Army Garrison Presidio of Monterey Command Policy #17.
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SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.
SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.
APPLICATION FOR INSTALLATION ACCESS
(FOR U.S. CITIZEN APPLICANTS ONLY)
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY: Public Law 110-181, The 2008 National Defense Authorization Act, Section 109.
PRINCIPAL PURPOSE: Provide necessary information to determine if applicant meets the installation access requirements in accordance with the U.S. Army Garrison, Presidio of Monterey Command Policy # 17, Installation Access Procedures for Visitors. Use of Date of Birth, Driver's License number and Social Security Number (SSN) are necessary for positive identification of the applicant in the Department of Justice database. Use of SSN includes the full 9-digit or the last 4-digit only.
ROUTINE USE: National Crime Information Center Interstate Identification Index (NCIC III) criminal history check using the Department of Defense database.
DISCLOSURE IS VOLUNTARY: Disclosure of SSN and other information is voluntary. However, applicant's failure to provide full name, Date of Birth, Driver's License number, and SSN will result in a delay or denial of installation access. Sponsor's failure to provide Date of Birth and SSN when requesting a Defense Biometric Identification Data System (DBIDS) card for an applicant will result in denial of DBIDS card issue.
1. LAST NAME, FIRST NAME, MIDDLE INITIAL
DRIVER'S LICENSE NUMBER ISSUING STATE
SECTION I. SPONSOR'S INFORMATION (To be completed by the sponsor requesting personnel listed below for inclusion to the Installation Access Roster to permit entry to the U.S. Army, Presidio of Monterey, California. Sponsor will be responsible for all actions of their guests while on the installation).
a. SPONSOR'S LAST NAME, FIRST NAME, MIDDLE INITIAL
POM Form 7, October 2015 PREVIOUS EDITION IS OBSOLETE Page 1 of 2
g. PURPOSE OF VISIT (Please provide details in the space provided below)
e. CONTRACT EXPIRATION DATE (CONTRACTORS ONLY)
c. SPONSOR'S ORGANIZATION
TO
SIGNATURE
ACCESS ROSTER
DBIDS CARD
RENEWAL INITIAL REQUEST
DATE
TO
MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY
d. DATE OF BIRTH (MM/DD/YYYY)
Enter Sponsor's Full SSN. This is required to verify enrollment in the Defense Enrollment Eligibility Reporting System (DEERS)
FROM FROM
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF BIRTH (MM/DD/YYYY)
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
Mission Requirement Other
f. TYPE OF REQUEST (Select one only)
SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.
3. LAST NAME, FIRST NAME, MIDDLE INITIAL
DRIVER'S LICENSE NUMBER ISSUING STATE
TO TO
MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY
FROM FROM
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF BIRTH (MM/DD/YYYY)
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
2. LAST NAME, FIRST NAME, MIDDLE INITIAL
DRIVER'S LICENSE NUMBER ISSUING STATE
TO TO
MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY
FROM FROM
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF BIRTH (MM/DD/YYYY)
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
Information collected in this form is FOR OFFICIAL USE ONLY. Sponsors will collect the required applicant information individually and not provide applicant access to each other's protected personal information. Once completed, if submitted via email using government computer, this application must be sent encrypted to the shared access email address: usarmy.pom.106-sig-bde.list.pres-installationaccess@army.mil. If using personal email, ensure that the security of your email system is adequate for sending sensitive information before choosing to transmit as this contains Personally Identifiable Information.
SECTION II. INFORMATION ON U.S. CITIZEN APPLICANT(S)
b. SPONSOR'S WORK PHONE (Area Code and Number)
SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.
APPLICATION FOR INSTALLATION ACCESS
(FOR U.S. CITIZEN APPLICANTS ONLY)
FOR APPROVING AUTHORITY USE ONLY
FOR LAW ENFORCEMENT USE ONLY
DATEPRINTED NAME SIGNATURE
POM Form 7, October 2015 PREVIOUS EDITION IS OBSOLETE Page 2 of 2
SECTION II. INFORMATION ON U.S. CITIZEN APPLICANT(S) (Continuation page)
APPROVED
DISAPPROVED
DISQUALIFYING FACTORS
YES NO
DATE NCIC III CONDUCTED
4. LAST NAME, FIRST NAME, MIDDLE INITIAL
DRIVER'S LICENSE NUMBER ISSUING STATE
TO TO
MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY
FROM FROM
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF BIRTH (MM/DD/YYYY)
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
5. LAST NAME, FIRST NAME, MIDDLE INITIAL
DRIVER'S LICENSE NUMBER ISSUING STATE
TO TO
MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY
FROM FROM
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF BIRTH (MM/DD/YYYY)
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
6. LAST NAME, FIRST NAME, MIDDLE INITIAL
DRIVER'S LICENSE NUMBER ISSUING STATE
TO TO
MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY
FROM FROM
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF BIRTH (MM/DD/YYYY)
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
7. LAST NAME, FIRST NAME, MIDDLE INITIAL
DRIVER'S LICENSE NUMBER ISSUING STATE
TO TO
MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY
FROM FROM
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF BIRTH (MM/DD/YYYY)
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
8. LAST NAME, FIRST NAME, MIDDLE INITIAL
DRIVER'S LICENSE NUMBER ISSUING STATE
TO TO
MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY
FROM FROM
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF BIRTH (MM/DD/YYYY)
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.
SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.
APPLICATION FOR INSTALLATION ACCESS
(FOR U.S. CITIZEN APPLICANTS ONLY)
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY: Public Law 110-181, The 2008 National Defense Authorization Act, Section 109.
PRINCIPAL PURPOSE: Provide necessary information to determine if applicant meets the installation access requirements in accordance with the U.S. Army Garrison, Presidio of Monterey Command Policy # 17, Installation Access Procedures for Visitors. Use of Date of Birth, Driver's License number and Social Security Number (SSN) are necessary for positive identification of the applicant in the Department of Justice database. Use of SSN includes the full 9-digit or the last 4-digit only.
ROUTINE USE: National Crime Information Center Interstate Identification Index (NCIC III) criminal history check using the Department of Defense database.
DISCLOSURE IS VOLUNTARY: Disclosure of SSN and other information is voluntary. However, applicant's failure to provide full name, Date of Birth, Driver's License number, and SSN will result in a delay or denial of installation access. Sponsor's failure to provide Date of Birth and SSN when requesting a Defense Biometric Identification Data System (DBIDS) card for an applicant will result in denial of DBIDS card issue.
SECTION I. SPONSOR'S INFORMATION (To be completed by the sponsor requesting personnel listed below for inclusion to the Installation Access Roster to permit entry to the U.S. Army, Presidio of Monterey, California. Sponsor will be responsible for all actions of their guests while on the installation).
POM Form 7, October 2015 PREVIOUS EDITION IS OBSOLETE Page 1 of 2
g. PURPOSE OF VISIT (Please provide details in the space provided below)
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
f. TYPE OF REQUEST (Select one only)
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
Information collected in this form is FOR OFFICIAL USE ONLY. Sponsors will collect the required applicant information individually and not provide applicant access to each other's protected personal information. Once completed, if submitted via email using government computer, this application must be sent encrypted to the shared access email address: usarmy.pom.106-sig-bde.list.pres-installationaccess@army.mil. If using personal email, ensure that the security of your email system is adequate for sending sensitive information before choosing to transmit as this contains Personally Identifiable Information.
SECTION II. INFORMATION ON U.S. CITIZEN APPLICANT(S)
APPLICATION FOR INSTALLATION ACCESS
(FOR U.S. CITIZEN APPLICANTS ONLY)
FOR APPROVING AUTHORITY USE ONLY
FOR LAW ENFORCEMENT USE ONLY
POM Form 7, October 2015 PREVIOUS EDITION IS OBSOLETE Page 2 of 2 SECTION II. INFORMATION ON U.S. CITIZEN APPLICANT(S) (Continuation page)
DISQUALIFYING FACTORS
DATE NCIC III CONDUCTED
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
DAYS REQUESTED ACCESS
TIME OF REQUESTED ACCESS
DATE OF REQUESTED ACCESS (MM/DD/YYYY)
8.0.1291.1.339988.308172
| Please enter the last 4-digit only of your SSN.: |
| TextField1: |
| Please select ISSUING STATE using the drop-down menu.: AL |
| Please select ISSUING STATE using the drop-down menu.: AL |
| Please select ISSUING STATE using the drop-down menu.: AL |
| Please select ISSUING STATE using the drop-down menu.: AL |
| Please select ISSUING STATE using the drop-down menu.: AL |
| Please select ISSUING STATE using the drop-down menu.: AL |
| Please select ISSUING STATE using the drop-down menu.: AL |
| Please select ISSUING STATE using the drop-down menu.: AL |
| "FOR CONTRACTOR'S ONLY". Please enter your Contract Expiration Date using the date format as MM/DD/YYYY or use the Calendar.: |
| Please enter the START TIME OF REQUESTED ACCESS using the Drop-Down Menu.: |
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| Please enter the FROM DATE OF REQUESTED ACCESS using the date format as MM/DD/YYYY or use the Calendar.: |
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| Please enter your Date of Birth using the date format as MM/DD/YYYY or use the Calendar.: |
| Please enter your Date of Birth using the date format as MM/DD/YYYY or use the Calendar.: |
| Please provide as much details on the purpose of the visit.: |
| Please enter area code + phone number using numerical characters only, e.g., enter (222) 333-4444 as 2223334444: |
| Please enter the Date NCIC III was conducted the date format as MM/DD/YYYY or use the Calendar.: |
| SignatureField1: |
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