B08 - Attachment 0004 - Access Control Record Check Form.pdf

ROCK ISLAND ARSENAL ACCESS CONTROL RECORD CHECK

Visitors are Welcome to RIA

Purpose: The United States Army requires a criminal records check be conducted on all visitors not affiliated with the Department of Defense or US Government.

SECTION I

NAME (Last, First, Middle Name) LAST FOUR OF SOCIAL SECURITY#

I 11 I

E-MAIL DATE OF BIRTH (DAY/MONTH/YEAR)

I IOI 11 I

OTHER NAMES USED (No nicknames) RACE Place of birth SEX U.S.CITIZEN

I 11 I IM OF 0 y ON 0

CURRENT HOME ADDRESS

NUMBER AND STREET CITY STATE ZIP CODE

I 11 11 11 I

PURPOSE OF VISIT

LOCATION: OFFICIAL BUSINESS RECREATIONAL VISIT

0 FIRSTARMY 0 CHRA/CPAC 0 GARRISON □ CEMETERY 0 HISTORIC SITES

0 ARDEC 0 COMMISSARY/PX O JOINT MUNITIONS □ DINING 0 LOCK&DAM

0 ARMY CORPS OF 0 CONTRACTING COMMAND CLUB HOUSE VISITOR CENTER

ENGINEERS 0 CREDIT UNION 0 JMTC □ FISHING 0 MUSEUM

□ ARMY SUSTAINMENT □ ECBC 0 RESERVE CENTER □ GOLF □ MWREVENT

COMMAND □ GYM

0 OTHER I I □ OTHER I I

PURPOSE OF VISIT:

GOVERNMENT POINT OF CONTACT (For Official Business Visits Only)

NAME: I I PHONE: I I

LENGTH OF VISIT DATE: I I TO: I I

FREQUENCY OF VISIT: □ ONETIME 0 DAILY □ WEEKLY □ MONTHLY

OTHER:

RIA FORM 190-1, 22 MAR 2016

SECTION II

I HEREBY CONSENT TO THE RELEASE OF MY CRIMINAL HISTORY RECORDS.

PRIVACY ACT STATEMENT

I Authorize a representative of the Rock Island Arsenal, Directorate of Emergency Services to conduct my background check, to obtain any information relating to my criminal history record. I authorize the Rock Island Arsenal Police Department, conducting my investigation to disclose the record of my background investigation to the official responsible for making a determination of suitability or eligibility for access to Rock Island Arsenal. I understand that the information released by records custodians and sources of information is for OFFICIAL USE ONLY by the Rock Island Arsenal for the purposes stated and that it may be re-disclosed by the government only as authorized by law. I further understand that with the signing of this form I authorize additional background checks as may be needed by representatives of the Rock Island Arsenal for continuing access to the installation.

15. My information on this form is true, complete, and correct to the best of my knowledge.

a. SIGNATURE OF APPLICANT b. DATE

16. RETURN THIS FORM BY EMAIL, FAX OR MAIL TO:

Directorate of Emergency Services Visitor Control Center ATTN: Building# 23 (IMRI-ESS-A) Rock Island Arsenal Rock Island, IL 61299

Fax: 309-782-5029 Phone: 309-782-0551 Em ail: u sa rmy .ria .im com.mbx. usag-access-request@ma i l.m i I

You may also bring this completed form in person with you to the Visitor Control Center.

***** APPLICANT DO NOT WRITE BELOW THIS LINE*****

FITNESS DETERMINATION OFFICER OFFICIAL USE ONLY

SECTION Ill

REVIEWING AUTHORITY

□ APPROVED □ DISAPPROVED REASON DISAPPROVED

APPROVING AUTHORITY DATE

~----'ID

REMARKS

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RIA FORM 190-1, 22 MAR 2016