Battle Creek _ _ BASE ACCESS REQUEST.pdf

Directions for Completing Base Access Request

W.K Kellogg ANGB

Battle Creek, MI

In order to gain access to the W.K. Kellogg (Battle Creek) ANGB, an access form must be completed by each individual to receive an access badge. This access form grants the base Security Forces Squadron the ability to run a background check on you through the Law Enforcement Information Network (LEIN). Individuals may be denied access to the base, as a result of the information discovered through the LEIN check. Once this process is complete you will have 30 calendar days to pick up your access badge at the base.

1. Fill in your information for blocks 1 through 7e. Your current address should match what is on your driver’s license or valid government issued ID. If you hand write your information, print legibly. If we can’t read your hand writing you will be asked to resubmit the form.

2. Complete section II, blocks 9a through 9e.

3. If you completed steps 1 and 2 electronically, print the form.

4. Sign your signature in ink in Section 8 next to the X. Your signature must resemble your signature on your driver’s license. If they are too dissimilar, the access form will not be processed. A digital signature will not be accepted.

5. In block 12, scan your driver’s license or other form of government issued ID if you do not have a driver’s license.

A Costco, Sam’s club, or other ID from a big chain store is not a valid ID. Yes, this has happened.

6. If you have an updated address sticker on the back of your license, it must also be included in block 12 when you scan it.

7. Look at the scan of your license or valid ID, if you can’t read it, we can’t read it. You will be asked to re-accomplish the access form to include a scan that is legible. Name the electronic file of your scan in the following format: last name, first name (Smith, John). This helps with tracking your form.

8. Access forms will be accepted from the general contractor only, ideally from one point of contact.

Subcontractors will email access forms to the general contractor. Despite the direction at the top of the form, email the completed forms to: nathan.d.finfrock.mil@mail.mil and jamieson.b.taylor.nfg@mail.mil

Multiple access forms can be emailed at once; however, keep the total email size to less than 10 MB. The government email system limits email sizes to this size.

9. Please allow at least 3 days for the form to be processed. Once the form is processed, we will notify the general contractor POC if you are granted access.

10. You have 30 calendar days to pick up your access badge. This is done at the Visitor Control Center. This includes taking your picture and the printing of the badge. If you do not pick up your access badge within the 30 days, the access request form will be completed again.

Individuals who are denied access and want to know why can file a Freedom of Information Act request via the Wing webpage at https://www.110atkw.ang.af.mil/ mailto:nathan.d.finfrock.mil@mail.mil mailto:jamieson.b.taylor.nfg@mail.mil 1286777046N Cross-Out

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MALE (1) AMERICAN INDIAN / ALASKA NATIVE (2) ASIAN (3) WHITE (1) HISPANIC / LATINO

FEMALE (4) BLACK / AFRICAN AMERICAN (5) NATIVE HAWAIIAN / OTHER PACIFIC ISLANDER (2) NOT HISPANIC / LATINO

7. CURRENT ADDRESS AND PHONE NUMBER

7a. NUMBER AND STREET (Include Apartment No.) 7b. CITY 7c. STATE 7d. ZIP CODE 7e. PHONE NUMBER

APPLICANT'S SIGNATURE

9a. COMPANY NAME 10a. SPONSOR NAME 11a.

DAILY (Mon- Fri) 9b. GENERAL CONTRACTOR 10b. SPONSOR UNIT

WEEKLY (1-2 times per week) 9c. COMPANY CONTACT NUMBER 10c. SPONSOR CONTACT NUMBER

MONTHLY (1-2 times per month) 9d. JOB SITE 10d. SPONSOR SIGNATURE

9e. START DATE 11b. ACCESS EXPIRATION DATE

NO

PREVIOUS EDITION IS OBSOLETE. MS Excel 2007SF FORM 90, 3 July 2018

12. SCAN DRIVERS LICENSE IN THIS SPACE.

1. DATE OF REQUEST (YYYYMMDD)

2. NAME OF APPLICANT (Last, First, Middle(s), Alias)

3. SEX 5. RACIAL CATEGORY (X one or more) 6. ETHNIC CATEGORY

12. PERSON COMPLETING THIS REQUEST

12c. SIGNATURE12b. RANK12a. NAME (Last, First, Middle Name(s)) 12d. TITLE

14. DEROGATORY FINDINGS

4. DATE OF BIRTH (YYYYMMDD)

YES

BASE ACCESS REQUEST

AUTHORITY: Title 10 United States Code, Sections 504, 505, 508, and 12102; E.O. 9397.

PRINCIPAL PURPOSE: To determine eligibility of a prospective contractor to be allowed access into an Armed Forces of the United States intsallation.

ROUTINE USES: Information collected on this form may be released to law enforcement agencies engaged in the investigation or prosecution of acriminal act or the enforcement or implementation of a statute, rule, regulation or order; to any component of the Department of Justice for the purpose of representing the DoD.

DISCLOSURE: Voluntary; however, failure of the applicant to complete this form may result in refusal of access into an Armed Forces of the United States intsallation.

PRIVACY ACT STATEMENT

SECTION IV - (Frequency of Visits)

The data are for OFFICIAL USE ONLY and will be maintained and used in strict confidence in accordance with Federal law and regulations. Making a knowing and willful false statement on this Form may be punishable by fine or imprisonment or both. All information provided by you, which possibly may reflect adversely on your past conduct and performance, may have an adverse impact on your clearance for base access.

The person described above has applied for access to a secure military installation therefore a LEIN check is required for installation access to be granted.

12e. Agency: 110th Security Forces Squadron 12f. Agency Address: 34 Sabre Street, Battle Creek, MI 49035 12g. ORI#: MIAF00400

12h. LEIN COMPLETED DATE (YYYYMMDD)

PLEASE EMAIL COMPLETED FORM TO: usaf.mi.110-atkw.list.sfs-pass-and-id@mail.mil

SECTION I - (Applicant's Personal Information)

SECTION II - (Contractor/Vendor Info) SECTION III - (Sponsor Info)

SECTION V - (To be completed by Security Forces Pass and ID member completing records check)

8. I HEREBY CONSENT TO A CRIMINAL HISTORY CHECK AS REQUIRED

TO GAIN ACCESS TO A MILITARY INSTALLATION.

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