Attch 2 - 233 SFS 113_Blank.pdf

CONTROLLED UNCLASSIFIED INFORMATION – Law Enforcement Sensitive ** LAW ENFORCEMENT SENSITIVE: The information in this document marked may contain Controlled Unclassified

Information (CUI) information that must be protected under the Privacy Act of 1974. Do not release outside of DOD channels without the consent of the originator's office.**

233 SFS FORM 113, 20150415 THIS FORM IS VALID FOR THE DURATION REQUESTED FROM THE

START TO END DATE, NOT TO EXCEED ONE CALENDAR YEAR.

APPLICATION FOR DEFENSE BIOMETRIC IDENTIFICATION SYSTEM (DBIDS)

CARD/VISITOR PASS

(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)

AUTHORITY: Title 10, United States Code 8012.

PRINCIPLE PURPOSE: To assist security personnel in establishing a fitness determination through the identity proofing and vetting (background check) process.

INTENDED USE: To be utilized by personnel requesting to obtain guest installation access pass for unescorted access to the Greeley Air National Guard Station

(GANGS).

DISCLOSURE: Disclosure of requested information is voluntary; however, failure to provide information may result in denial of request or the refusal by the 233d Security Forces Squadron, Pass and Registration Center (233 SFS PRC) to permit issuance of an installation access pass. By signing this application, the applicant understands if they lose their installation access pass, they will report the loss immediately to their sponsor and the Base Defense Operations Center (BDOC) Controller, (970)378-5084.

INSTRUCTIONS

1. Sponsor to submit form to 233 SFS POC (BUILDING 100 RM 112), via TEAMS, or a digitally signed email to the SFS representative. All information must be completed or the form signed or it will be denied.

2. Visitor must present Government issued photo ID in order to establish identity, without a GOV issued ID go to https://dbids-global.dmdc.mil/enroll#!/

3. Sponsor MUST be registered in DBIDS prior to submitting form.

SECTION I: SPONSOR WILL ENSURE ALL BLOCKS ARE COMPLETE AND LEGIBLE

1. SPONSOR NAME (Last, First, MI) 2. SPONSOR UNIT / PHONE #

3. DOES VISITOR REQUIRE RA ACCESS? 4. INSTALLATION ACCESS DATE(S)

TO

5. ACCESS HOURS 6. REASON FOR GUEST VISIT

VISITOR INFORMATION (QH, QR)

7. NAME (Last, First, MI) 8. SSN 9. DATE OF BIRTH (YYYYMMDD) 10. DRIVER LICENSE # / STATE ISSUED

11. HEIGHT 12. WEIGHT 13. GENDER 14. EYE

COLOR

15. HAIR

COLOR

16. WORK / CELL PHONE 17. COMPANY / ORGANIZATION

THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED STATES CODE, SECTION 1001 OR OTHER APPLICABLE LAWS AND REGULATIONS.

ALL SIGNATURE BLOCKS MUST BE SIGNED

NOTE: "SPONSOR AND/OR GUEST" SHALL RETURN BADGE TO 233d SFS POC UPON EXPIRATION

18. SPONSOR SIGNATURE DATE

19. VISITOR SIGNATURE DATE

SECTION II: VEHICLE INFORMATION (QV, KQ)

THIS SECTION MUST BE COMPLETED IF YOU REQUIRE TO BRING A VEHICLE ONTO THE INSTALLATION. OPERATOR MUST BE VISITOR NAMED ABOVE.

20. VEHICLE MAKE 21. VEHICLE MODEL 22. VEHICLE YEAR 23. PRIVATE OWNER / COMMERCIAL

23. VEHICLE COLOR 24. VEHICLE BODY TYPE 25. VIN

26. LICENSE PLATE TYPE/ REG. EXPIRATION

DATE

27. LICENSE PLATE ISSUER (STATE) 28. LICENSE PLATE NUMBER

29. INSURANCE PROVIDER 30. POLICY NUMBER 31. POLICY EXPIRATION DATE

SECTION III: TO BE COMPLETED BY 233d SECURITY FORCES PASS AND REGISTRATION STAFF ONLY

NCIC CHECK CONDUCTED BY (PRINT/SIGN):

FAVORABLE DEROGATORY

DATE:

PASS ISSUED BY / DATE: DATE EXPIRES: