Attachment A - af2586_new.pdf

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UNESCORTED ENTRY AUTHORIZATION CERTIFICATE

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 8013, 44 U.S.C. 3101, and EO 9397.

PRINCIPAL PURPOSE(S): To record personal information on an individual whose duty performance requires entry into Air Force restricted and controlled areas in order to coordinate with the appropriate official and determine when and what type of entry credential to use.

Control Number is used for individual identification. (Must be from government-issued ID such as CAC, driver license, passport, etc.)

ROUTINE USE(S): None.

DISCLOSURE: Disclosure is voluntary however, failure to disclose information and SSN would result in not being allowed entry into these areas.

I. IDENTIFICATION

GRADE

Control Number

ORGANIZATION OR FIRM

HEIGHT

WEIGHT

COLOR EYES

COLOR HAIR

US CITIZEN

ALIEN IMMIGRANT

NON-US NATIONAL

II. CERTIFICATION OF REQUESTING OFFICIAL

I certify that the individual whose name appears above has been the subject of a favorable investigation which meets the requirements of AFIs 31-101, 31-209 and 31-501, when applicable, for unescorted entry into restricted or controlled areas. I further certify, in the event the above named individual is a non-US national, that no US nationals can be made available to fill this position during the period indicated above, and that the granting of unescorted entry represents an exceptional requirement essential to the proper execution of the Command's mission. Such unescorted entry will not infringe upon the prohibited duties outlined in AFPD 31-series directives, and is clearly consistent with the interest of national security.

SIGNATURE

DATE

III. DUTY

(Describe duties that require unescorted entry into the areas indicated)

IV. RESTRICTED/CONTROLLED AREA COORDINATION

AREA

NUMBER

ESCORT

OFFICIAL

CONCUR

COORDINATING/APPROVING

OFFICIAL'S SIGNATURE

TYPE AREA

DATE

YES

NO

PREVIOUS EDITIONS ARE OBSOLETE.

AF IMT 2586, 19981001, V2

Signature Signature Signature Signature Signature NAME, GRADE AND TITLE (Typed) Signature CITIZENSHIP (Check One) Signature NAME (Last, First, Middle Initial) Signature

IV. RESTRICTED/CONTROLLED AREA COORDINATION

AREA

NUMBER

ESCORT

OFFICIAL

CONCUR

COORDINATING/APPROVING

OFFICIAL'S SIGNATURE

TYPE AREA

DATE

YES

NO

V. RESTRICTED/CONTROLLED AREA BADGE ISSUE

BADGE NUMBER

TRANSACTION

FORM TYPE

CARD NUMBER

BASIC BADGE

EXCHANGE BADGE #1

EXCHANGE BADGE #2

EXCHANGE BADGE #3

REISSUE #1

REISSUE #2

REISSUE #3

REISSUE #4

REISSUE #5

DATE

REMARKS

AF IMT 2586, 19981001, V2 (REVERSE)

Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature BADGE ISSUING OFFICIAL (Typed Name and Signature) Signature APPLICANT VERIFYING RECEIPT OF BADGE (Signature) Signature 8.2.1.3158.1.475346.466429

COMPANY NAME:

CONTRACT NUMBER:

PERFORMANCE START DATE:

PERFORMANCE END DATE:

PROGRAM MANAGER:

PROGRAM OFFICE SYMBOL: 78 CEG/CENME

PM DUTY PHONE:

PM BUILGING # 280

REQUIRE ESCOURT PRIVILEDGES IN THE INDUSTRIAL AREA