Base Pass Template.pdf
PDF 205 KB Posted
- Solicitation number
- FA483025R0007
About this file
The document is a Request for Installation Access template for the 23d Security Forces Squadron at Moody Air Force Base in Georgia. The form is designed to request base access passes for personnel, requiring details such as full name, last 6 digits of SSN/DOB, organization, and an expiration date not exceeding one year. The form emphasizes that the information is Controlled Unclassified Information (CUI) protected under the Freedom of Information Act of 1996 and Privacy Act of 1974, with potential disciplinary or legal consequences for unauthorized disclosure. The document includes fields for a brief synopsis explaining the reason for installation access and space for an authorizing official's signature and duty title.
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Text version
FOR OFFICIAL USE ONLY
DEPARTMENT OF THE AIR FORCE
23D SECURITY FORCES SQUADRON (ACC)
MOODY AIR FORCE BASE GEORGIA
MEMORANDUM FOR 23 SFS
FROM: Squadron or Person/Company Requesting Access
SUBJECT: Request for Installation Access
1. I am requesting a pass for the following people to Moody AFB for the purpose of (state reason and location personnel will be traveling to on base, please be specific).
Full Name: as they appear on their valid state ID.
Last 6 of
SSN/DOB
Organization/Company /School Name:
Expiration Date:
(not to exceed 1yr)
2. Brief synopsis of the situation: (explain the situation that requires the individual to have access to the installation).
First M. Last Name, Rank, USAF Duty Title
Attack · Rescue · Prevail The information here is Controlled Unclassified Information (CUI) which must be protected under the Freedom of Information Act of 1996 and Privacy Act of 1974, as amended. Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in disciplinary action, criminal and/or civil penalties.
| Full Name as they appear on their valid state IDRow1: |
| Last 6 of SSNDOBRow1: |
| OrganizationCompany School NameRow1: |
| Expiration Date not to exceed 1yrRow1: |
| Full Name as they appear on their valid state IDRow2: |
| Last 6 of SSNDOBRow2: |
| OrganizationCompany School NameRow2: |
| Expiration Date not to exceed 1yrRow2: |
| Full Name as they appear on their valid state IDRow3: |
| Last 6 of SSNDOBRow3: |
| OrganizationCompany School NameRow3: |
| Expiration Date not to exceed 1yrRow3: |
| Full Name as they appear on their valid state IDRow4: |
| Last 6 of SSNDOBRow4: |
| OrganizationCompany School NameRow4: |
| Expiration Date not to exceed 1yrRow4: |
| Full Name as they appear on their valid state IDRow5: |
| Last 6 of SSNDOBRow5: |
| OrganizationCompany School NameRow5: |
| Expiration Date not to exceed 1yrRow5: |
| Full Name as they appear on their valid state IDRow6: |
| Last 6 of SSNDOBRow6: |
| OrganizationCompany School NameRow6: |
| Expiration Date not to exceed 1yrRow6: |
File details come from the government source that posted it. Updated .