Attachment T4-Sponsored_Pass_Application-_Fort_Belvoir_Installation_Access.pdf

State

SPONSORED PASS APPLICATION- FORT BELVOIR INSTALLATION ACCESS

U.S. Passport Number (if driver's license or state ID is not available)

SPONSOR’S CERTIFICATION: I certify that the applicant meets the justification requirements and that they require a PASS as indicated above in order to perform assigned duties, conduct official business or visit family/friends on Fort Belvoir. I understand my role as the sponsor and ensuring the PASS is retrieved upon expiration or prior to expiration if it is no longer required. If I fail to do so, my ability to be an approved sponsor can be removed.

Section Below Completed by the Visitor Control Center

Sponsor Signature Date

Your Destination on Fort Belvoir Justification for Access acce Work Visiting Other:________________________

Permanent Resident Card Number (Form I-551) (if applicable)Employment Authorization Card Number (Form I-766) (if applicable)

Applicant Certification: I certify the information provided is true and accurate, and I am providing it with the purpose of receiving a ACCESS PASS to allow access onto Fort Belvoir. I understand that I am required to turn in or destroy the pass upon expiration or prior to expiration. If I fail to due so my access to Fort Belvoir can be denied for any and all future requests. I understand that I must give Fort Belvoir Visitor Control Center consent to an initial and periodic background screenings prior to and after the issuance of an installation access badge/pass. Failure to do so will result in the termination of the application process. I understand that my access may be revoked at anytime without reason or notice. I understand that I must immediately report any lost or stolen pass to the Visitor Center. I further understand that these background screenings will determine my eligibility for access and continued access during the term of my request.

Applicant Signature Date

Driver's License or State Identification Card Number

PRIVACY ACT ADVISEMENT: The information requested is for the purpose of granting access to the Fort Belvoir Installation. Providing requested information, to include your social security number (SSN), is voluntary. However, your access may not be granted if all requested information is not provided. AUTHORITIES: Executive Orders (EO) 10450, 10865, and 12333. The SSN, required for record accuracy, is requested pursuant to EO 9397. All information that contains PII is protected as required.

VISITOR APPLICANT INFORMATION

Issuing Official Name Today's Date Expiration Date

SPONSOR INFORMATION

Sponsor must work or live on Fort Belvoir. Sponsor working on Fort Belvoir must be Active Duty U.S. Military or DoD Civilian. Sponsor living on Fort Belvoir must be Active Duty U.S. Military or Dependent ID card holder (18yrs of age and older).

Name (last, first, middle initial) Grade / Rank or Dependent

DoD Email Address

Home Address (if you live on the installation) Contact Phone Number

Organization / Unit Address

Name (last, first, middle initial) Social Security Number (full SSN required)

Date of Birth year ____________ month ____________ day ____________

Gender

Male Female

Requested Pass Duration (when do you want their pass to expire; not to exceed 1 year)

Email Address Contact Phone Number

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