Attachment A- Access Procedures - Camp Roberts - USASACR Vetting Form V5 23 May 2023.pdf

SATCOM CAMP ROBERTS ACCESS REQUEST FORM

(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF

1974) ALL REQUESTS MUST BE SUBMITTED IN

TO THE VISITOR CONTROL CENTER OR PHYSICAL SECURITY OFFICE

ROUTINE VISITS AND OTHER

Initial Renew

SPECIAL EVENTS (CHECK ONE)

CONTRACTOR/VENDOR ACCESS Initial Extend

CREDENTIAL (CHECK ONE)

Complete this form and return to your USASA-CR sponsor. A National Crime and Information Center (NCIC) check will be conducted prior to granting access to the installation.

By completing this application, you affirm/swear the information provided is true. That a knowing and willful false statement on this application can be punished by being barred from the installation, a fine, imprisonment or both. (18 U.S.C. Section 1001). Furthermore, that under the authority of 50 U.S.C. Section 797 and DoD 5200.8, the installation commander has imposed a continuing obligation for you to disclose. Questions may be directed to the Physical Security office at (805) 227-7625.

Section 1. PERSONAL INFORMATION (FAILURE TO PROVIDE ALL INFORMATION MAY RESULT IN DENIED ACCESS)

1. LAST 2. FIRST 3. MIDDLE 4. DRIVER’S LICENSE NUMBER 5. DL EXPIRE DATE 6. DL STATE 7. SOCIAL SECURITY NUMBER

8. DATE OF BIRTH (YYYYMMDD) 9. EYE COLOR 10. HAIR COLOR 11. HEIGHT 12. WEIGHT 13. SEX 14. RACE

15. HOME PHONE NUMBER 16. WORK PHONE NUMBER 17. CURRENT STREET ADDRESS 18. CITY 19. STATE 20. ZIP CODE

Section 2. PLACE OF BIRTH

1. CITY 2. STATE (If applicable) 3. COUNTRY

5. U.S. CITIZEN? Y/N (If no, see notes 1 and 2 on next page) 6. LIST IMMIGRATION DOCUMENT TITLE, DOCUMENT NUMBER, AND EXPIRATION DATE (If applicable)

Section 3. CONTRACTOR/VENDOR INFORMATION (IF APPLICABLE) The following company/organization is providing either vendor’s service or holds a contract with our organization. The individual is required to enter USASA-CR, CA in an official capacity on a regular basis. Request the issuance of an access credential.

The below listed individual understands that this is an identification credential, not a sponsoring credential and that it will not allow entry into any facilities other than the installation gates. Use of this credential is strictly for business purposes only. Individual agrees to adhere to all vehicle regulations and guidelines set forth by AR 190-5, Army Motor Vehicle Regulation and those set by the installation commander.

1. COMPANY / ORGANIZATION NAME 2. FULL ADDRESS OF COMPANY / ORGANIZATION 3. CITY 4. STATE 5. ZIP CODE

Section 4. GOVERNMENT SPONSOR OR CONTRACT REPRESENTATIVE - AUTHORIZING INFORMATION Upon termination of contract, employee termination, or expiration of the access credential the Authorizing Official will retrieve the credential from the contractor and return it to buildings 18021 ACP or Physical Security. The Government Sponsor must complete their portion before it is accepted at the Access Control Point. Being a sponsor you assume all responsibility for your visitor while they are on the installation.

1. LAST 2. FIRST 3. MIDDLE 4. SPONSOR'S PHONE NUMBER & EMAIL 5. SPONSOR'S OFFICIAL TITLE

6. SPONSOR'S ORGANIZATION 7. SPONSOR'S CONTRACT NUMBER (Required if sponsoring a contractor) 8. CONTRACT EXPIRATION DATE

THE SPONSOR AGREES TO ACCEPT RESPONSIBILITY FOR THEIR VISITOR(S) WHILE ON THE INSTALLATION:

SPONSOR’S SIGNATURE: DATE:

Section 5. WARNING: CONSENT TO SUBJECT SEARCH/SEIZURE, VEHICLE TOWING, REIMBURSEMENT, IMPOUNDMENT

By accepting a visitor/contractor pass you give your consent to search of your vehicle while it is entering on, or leaving USASA-CR. If your vehicle is towed or impounded, you agree to reimburse the towing agent on behalf of the vehicle owner/operator.

Section 6: ATTESTATION

I understand the information on this form is being collected in accordance with 50 U.S.C., Section 797, and DoD 5200.8, and federal laws. Permitting the installation commander to limit access to the installation for security reasons and that this data will be used to screen personnel who have or are seeking access to USASA-CR. I have voluntarily completed this form and shall provide the Army a specimen of my fingerprints, if/when requested. I understand (a) criminal offense(s) may be prosecuted in federal court. The information I have provided on this application is true, complete, and correct to the best of my knowledge and belief, and is provided in good faith. I understand that a knowing and willfully false statement on this application can be punished by fine or imprisonment or both (18 U.S.C section 1001).

Date(s) of visit/contract term requested: Date of Request:

Purpose of visit:

Section 7. Access Denials Should access be denied, you may request a denial wavier through the Directorate of Emergency Services-Physical Security Office the point of contact for denial wavier actions. Follow the instructions on second page of the wavier for submittal instructions, address, and documentation requirements.

Section 8. PRIVACY ACT STATEMENT Authority: 50 USC Section 797; E.O.9397

PRINCIPAL PURPOSE(S): The purpose for requesting personal information is to assist Access Control personnel in documenting visitors’ suitability for access to USASA-CR. Social security number and date of birth are necessary to identify the person and records. This information may be used to determine suitability of person desiring access to USASA-CR as well as, for lawful purposes including law enforcement and litigation. This information will be used to generate state and federal criminal history records checks.

INTENDED USE: For all personnel who are not authorized a Common Access Card (CAC) or other federally authorized credential and require access to the installation for a special event and/or visit.

DISCLOSURE: Disclosure of requested information is voluntary; however, failure to provided information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the special event and/or visit.

For Official Use Only (FOUO), This document contains information exempt from mandatory disclosure under the FOIA. Title 5 U.S.C. 552 (b) (6) applies. This document also contains personal information that is protected by the Privacy Act of 1974 and must be safeguarded from unauthorized disclosure."

Section 9. Approval or Denial (To be completed by DES Personnel) 1.

Access Granted

2.

Access Denied

3. 4. 5.

Print Name Signature Date

6. DATE REQUEST RECEIVED: 7. DATE SPONSOR NOTIFIED OF APPROVAL/DISAPPROVAL:

INSTALLATION ACCESS REQUEST FORM, 28 DEC 2022.

All previous editions are obsolete.

CLETS MSG#

For Official Use Only (FOUO)

ACCEPTABLE DOCUMENTS FOR VERIFICATION OF IDENTITY/AUTHORIZATION TO WORK

REQUIRED DOCUMENTS BELOW:

ID card issued by a state or outlying possession of the United States provided it contains a photograph and information such as name, date of birth, gender, height, eye color, and address

ADDITIONAL DOCUMENT REQUIREMENTS:

SSN NUMBER

AND ONE OF THE FOLLOWING:

US Birth Certificate

US PASSPORT

CERTIFICATE OF NATURALIZATION (Form N-550 or N-570)

IF OPERATING A VEHICLE YOU MUST PRESENT A REAL ID ACT OF 2005 COMPLIANT VALID DRIVER

LICENSE, CURRENT REGISTRATION, AND PROOF OF VALID INSURANCE

NOTE:

1. No exception, must be U.S. Citizen. Citizenship will be verified.

2. Any foreign national who request access to USASA Camp Roberts may be subject to reporting to the FBI and an investigation may be conducted into their request.

3. ALL persons requesting a pass will be subject to vetting a records check through the National Crime Information Center (NCIC) Interstate Identification Index (III) is the minimum baseline background check for entrance onto Army Installations for non-CAC holders to include entrance of visitors and contractors. Vetting is to grant access and does grant the right to work, the government agent (COR) must coordinate with the anti-terrorism officer and the installation security manager for clearance for the contractors/vendors to perform services.

4. Persons who do not pass the security vetting will be denied access and provided with the process for submitting an appeal. The appeal process is governed by Army Directive 2014-05 and is non- waivable. The appeal process can take an extended period of time.

5. Access Control Point or Physical Security staff may contact a Company POC listed on the access request form to verify that the request for a pass is valid.

6. All information on the access request form must be completed. The completed form and the verification documents listed above are to be presented to the Physical Security Office. Access request forms may be emailed to all three of the following individuals: stephen.r.bray2.civ@army.mil, benjamin.q.lindsey.mil@army.mil, and william.j.norton20.civ@army.mil

7. Any conduct which is detrimental to the maintenance of good order and discipline on the USASA-CR/ Camp Roberts Military Installation may result in confiscation of the visitor pass/badge, immediate removal from the installation, and the imposition of a BAR.

8. The Government Agent (sponsor) has overall responsibility for the conduct of the pass holder at all times while they are on the Installation. While this does not include punitive liability, the Agent may be required to brief senior installation leaders regarding acts of employee misconduct.

9. Pass holders will confine themselves only to those areas related to issuance of the pass. Pass holders will not enter any marked, restricted and/or controlled areas. Specifically airfields, command headquarters, motor pools, military training facilities, areas where military weapons are present, fire stations, and communications facilities. Be prepared to identify yourself and the purpose of your presence on USASA-CR/Camp Roberts to police or security personnel at all times.

10. Vehicles and packages may be searched at any time while on the installation.

11. No Firearms/personal Weapons allowed for visitors with the exception of Law enforcement on official duty.

12. Concealed weapons permits are not valid on the installation.

Requestor Signature Date

Printed Name