Encl 10_MCASO 5500.2W Appendix.pdf

APPENDIX A MCASO 5500.2W

MCAS IWAKUNI Authorized Access Credentials

Appendix A contains samples of credentials that may authorize an individual access to Marine Corps Air Station (MCAS) Iwakuni. This list is not all-inclusive, and the presentation of a listed credential does not automatically grant access. PMO, under the direction and guidance of the MCAS Iwakuni CO, will make the final determination as to the validity and applicability of credentials presented for entry.

Common Access Card (CAC) The CAC is an ID card for active-duty military personnel, Selected Reserve, DoD civilian employees, eligible contractor personnel, and Master Labor Contract(MLC)/Indirect Hire Agreement(IHA) employees without DBIDS access credentials.

Card Topology

Card Types & Eligibility

Card Type Recipients Affiliation

1) Armed Forces of the United States Geneva Conventions Identification Card

The standard card for active duty personnel in accordance with Geneva Conventions requirements.

• Active Duty Armed Forces

• Selected Reserves

• Reserve and National Guard Members on active duty more than 30 days

• Contracted Reserve Officer Training Corps (ROTC) cadets

• National Oceanic and Atmospheric Administration (NOAA)

• U.S. Public Health Services (PHS)

• Displays branch of Service

A-1

2) U.S. DoD and/or Uniformed Services Identification Card qualifying civilian employees, contractors, and foreign national affiliates who need access to DoD installations, and computer systems.

• DoD and uniformed Services civilian employees (appropriated and non-appropriated)

• Eligible DoD, USCG, and NOAA contractors

• Non-DoD civilian employees to include: USCG and NOAA, state employees working in support of the National Guard, Intergovernmental Personnel Act employees, and non- DoD federal employees working in support of DoD

• Senior Executive Service (SES)

• Civilians

• Civilian affiliates

• Federal

• Military

3) U.S. DoD and/or Uniformed Services Geneva Conventions Identification Card for Civilians Accompanying the Armed Forces civilians accompanying the Armed Forces.

• Emergency-essential civilian employees

• Contingency contractor personnel

• Senior

• Contractors

A-2

4) U.S. DoD and/or Uniformed Services Identification and Privilege Card

The standard card granting applicable benefits and privilege for civilian employees, contractors, and foreign national military, as well as other eligible personnel.

• DoD and uniformed Services civilian employees (appropriated and nonappropriated) when residing on a military installation within the United States and U.S. Territories and Possessions, or when stationed or employed and residing in foreign countries for at least 365 days

• DoD contractors when stationed or employed and residing in foreign countries for at least 365 days

• DoD Presidential appointees

• Uniformed and non-uniformed full-time paid personnel of the Red Cross assigned to duty with the uniformed Services within the United States and U.S. Territories and Possessions, when residing on a military installation, or in foreign countries

• Eligible foreign military

• Senior

• Contractors

• Civilian

• Federal

• Military affiliate

5) DoD Civilian Retiree Card (Terminated)

• The Defense Department has stopped issuing new DOD Civilian Retiree identification (ID) cards and will no longer renew existing cards. Advancements in installation security access control systems and procedures, and the implementation of the REAL ID Act, have necessitated the termination of the DOD Civilian Retiree ID card. Previously issued cards will remain valid through Aug. 31, 2023.

Color Coding Blue Bar

Non-U.S. Citizen

Green Bar

Contractors

White

All Remaining Personnel

A-3

Next Generation Uniformed Services Identification (USID) Card ID Card for military family members and military retirees to access service benefits and privileges.

A-4

Card Type Recipients

1) “Reserve” Armed Forces of the United States

Geneva Conventions Identification Card

• Members of the Individual Ready Reserves and Inactive National Guard

• Non-CAC-eligible civilian noncombatant personnel deployed in conjunction with military operations overseas

2) “Retired” U.S. Department of Defense /

Sponsor Identification and

• Retired members entitled to retired pa

• Members of the Temporary Disability

Retired List (TDRL)

• Members of the Permanent Disability

Retired List (PDRL)

• Retired members of the Reserves and

National Guard

• Medal of Honor recipients

• 100% Disabled Veterans

• Former members in receipt of retired pay

• Transitional Health Care Member (TAMP)

• Full-time paid United Service

Organizations (USO) personnel when serving OCONUS

• United Seaman’s Service (USS) Personnel

OCONUS

• Officers and Crews of MSC vessels deployed to foreign countries

• Select Employer Support of the Guard and Reserve (ESGR) personnel

• Other benefits-eligible categories as described in DoD policy

Non-U.S. Citizen Sponsors and their

Dependents

White

Current/Former Uniformed Service Members, their Dependents, and All Remaining Personnel

A-5

Card Type Recipients

3) “Spouse” U.S. Department of Defense /

Dependent Identification and

Dependents of:

• Active duty Service members of the regular components

• Reserve component Service members on active duty for more than 30 days

• Retirees

• Medal of Honor recipients

• Former members in receipt of retired pay

• Transitional Health Care Members (TAMP)

• 100% Disabled Veterans

• Ship’s Officers and Crewmembers of NOAA

Vessels

• Reserve members not on active duty or in receipt of retired pay

• Former members not in receipt of retired pay

• Reserve Service members who die after receipt of NOE

Surviving Dependents of:

• Active duty and retired Service members

• Medal of Honor recipients

Legacy USID cards remain valid through their expiration date, however, individuals with an indefinite(INDEF) expiration date on their legacy USID card may replace those ID cards with a Next Generation USID card.

Legacy USID Card Type Recipients

1) DD Form 2 (Reserve)

Armed Forces of the United States Geneva Conventions Identification Card

• Members of the Individual Ready Reserves and Inactive National Guard

2) DD Form 2 (Retired)

United States Uniformed Services Identification Card

• Retired members entitled to retired pay

• Members of the Temporary Disability Retired List (TDRL)

• Members of the Permanent Disability Retired List (PDRL)

3) DD Form 2 (Reserve Retired)

Services Identification Card

• Retired members of the Reserves and National Guard under the age of 60

A-6

4) DD Form 1173

Services Identification and Privilege Card

• Dependents of: active-duty Service members of the regular components; Reserve component Service members on active duty for more than 30 days; retirees; Medal of Honor recipients; former members in receipt of retired pay; Transitional Health Care Members (TAMP); 100% Disabled American Veterans (DAV); and Ship's Officers and Crewmembers of NOAA Vessels

• Surviving dependents of: active-duty and retired military members; Medal of Honor recipients; and 100% Disabled American Veterans (DAV)

• Accompanying family members of authorized civilian personnel overseas

• Eligible dependents of foreign military

5) DD Form 1173-1

Privilege Card (Guard and Reserve family member)

• Dependents of: Reserve members not on Active Duty or in receipt of retired pay; former members not in receipt of retired pay;

Reserve Service members who die after receipt of Notice of Eligibility

A-7

6) DD Form 2765

Department of Defense/Uniformed

• Medal of Honor recipients

• 100% Disabled American Veterans (DAV)

• Former members in receipt of retired pay

• Transitional Health Care Member (TAMP)

• Full-time paid personnel of the USO when serving outside the United States

• United Seaman's Service (USS) personnel when serving outside the United States

• Officers and Crews of MSC Vessels deployed to foreign countries

• Select Employer Support of the Guard and Reserve (ESGR) personnel

A-8

Defense Biometric Identification System (DBIDS) Card The Commanding Officer, MCAS Iwakuni has the overall responsibility and authority to ensure that 100 percent of all personnel entering MCAS Iwakuni are properly identified, fit for access, and have a legitimate purpose for access to MCAS Iwakuni. The integration of the Defense Biometric Identification System (DBIDS) assists with the identification and fitness of personnel attempting to access MCAS Iwakuni.

MLC/IHA, JSDF,

Foreign Contractor

Red Bar

Emergency Essential Employee

Green Bar

U.S. Contractor

Yellow Bar

Other

– Not Contractor, MLC or Foreign

Civilian Employee

DBIDS Paper Pass

A-9

Department of State One Badge

USFJ453 (USFJ Installation Access Card)

A-10

APPENDIX B MCASO 5500.2W

MCAS Iwakuni DBIDS Credential Request

B-1

PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. 301; 10 U.S.C. 5031; 44 U.S.C. 3103 AND EO 9397

PRINCIPAL PURPOSE: Used to record information and details of criminal activity which may require investigative action by commanding officers, supervisors, NCIS, etc. Used to provide information to the appropriate individuals within DoD organizations who ensure that proper legal and administrative action is taken.

ROUTINE USES: Information may be disclosed to local, county, state, and federal law enforcement or investigatory authorities for investigation and possible criminal or civil court action. Information extracted from this form may be used in other related criminal and/or civil proceedings.

DISCLOSURE: Voluntary. Information is used to positively identify the individual making the statement and to check past criminal activity records. Failure to disclose any information may result in delay of processing.

PERSONNEL TYPE (CHECK ONE)

□ JMSDF Permanent Party Personnel

□ JMSDF Dependent OR JMSDF Retired

□ MLC/IHA

□ MLC/IHA Dependent OR MLC/IHA Retired

□ U.S. Contractor

□ JN Contractor

□ TCN Contractor

□ DTCN Contractor (Signed Appendix G)

□ Other (JGSDF, JASDF, U.S. Government Official, Authorized Insurance Agents, OR ___________________________________________________________________________)

Applicant Name (LAST, First M) (申請者名): ________________________________

COMMAND (BRANCH/UNIT/COMPANY) OR ORGANIZATION/DIVISON/CONTRACT

OF MCAS IWAKUNI

SPONSORING AGENCY POC TELEPHONE SPONSORING AGENCY POC EMAIL

CONTRACT NUMBER (CTR ONLY) CONTRACT WORK SITE LOCATION (CTR ONLY) CONTRACT START (DD/MMM/YYYY) CONTRACT END (DD/MMM/YYYY)

Sponsoring Agency Contract Manager/Supervisor(for MLC/IHA Retirees, CHRO) :

Sponsoring Agency (契約元機関名)

Supervisor Print (監督者名) Signature of Supervisor (署名) Date (日付)

Department Head (for MLC/IHA Retirees, Director of CHRO or Designee):

Department Head Print (部門・部隊長名) Signature of Department Head (署名) Date (日付) *Personnel Authorized by Appendix M

Provost Marshal or Designee:

Approved / Disapproved

Provost Marshal/Designee Print Signature Date(日付)

CUI

APPENDIX B MCASO 5500.2W

MCAS Iwakuni DBIDS Credential Request

B-2

To be completed by PMO / 憲兵隊記入欄

DBIDS# EXPIRE DATE (DD/MMM/YYYY)

APPLICANT INFORMATION To be completed by applicant：申請者記入欄

APPLICANT NAME (LAST, FIRST M)

氏名 ローマ字

氏名 漢字

SEX 性別

SSN:( ) PASSPORT:( )

ALIAN REGISTRATION CARD:( )

DRIVER’S LICENSE:( )

MY NUMBER:( )

**ALIASES NAME, MAIDEN NAME, or OTHER NAME which were previously or/and currently used (Write down FULL NAME (L,F M)/Kanji, Print Name and Katakana) 別名(通称名)、旧姓、旧氏名など、現在の戸籍上の氏名以外で使用されている、又は、使用されたことのある全ての名前（全てフルネームを漢字、ローマ字、カタカナで記入）

DATE OF BIRTH (DD/MMM/YYYY)

生年月日

PLACE OF BIRTH(CITY,STATES and

COUNTRY) 出生地（市,県および国）

NATIONALITY 国籍 RACE 人種 CURRENT CITIZENSHIP

現在の市民権

FORMER CITIZENSHIP

以前の市民権

PERMANENT FULL ADDRESS 本籍地

ローマ字

漢字

CURRENT FULL ADDRESS 現住所

ローマ字

漢字

EYE COLOR 目の色 HAIR COLOR 髪の色 HEIGHT 身長

inch cm

WEIGHT 体重

pound kg

RANK ランク(自衛官の場合)

APPLICANTS’ CONTACT NUMBER 申請者連絡先電話番号 MOS/OCCUPATION/JOB TITLE 職務又は職種

HELD PREVIOUS PASS? 過去のパス取得の有無

YES NO (Pass No: )

PRIMARY COMPANY NAME 元請会社名 WORK TELEPHONE 元請会社電話番号/自衛隊内線

REQUEST HOURS OF GATE ACCESS

希望する入門時間

REQUEST DAY(S) OF GATE ACCESS

希望する入門曜日

VOLUNTARY DISCLOSURE

State honestly if applicant has previously been involved in an offense of criminal activity or violations of road traffic law. Willfully providing inaccurate or false information will result in permanent revocation of pass.

今までに道路交通法違反、刑法違反を犯したことが ある人は、正直にここに書いて下さい。故意に不明確だったり偽り

の内容を記入した場合は パスの永久発行停止となります。

1)Criminal Act 刑法違反 ( ) Yes あり ( ) No なし

2)Road Traffic Violation 道路交通法違反 ( ) Yes あり ( ) No なし

If yes, please provide a description of the incident(s). 上記違反内容を述べて下さい。

Applicant:

I verify by my signature below that I will comply all rules and policies associate with issuance of the DBIDS Credential

Applicant Print (申請者名) Signature of Applicant (署名) Date (日付)

APPENDIX C MCASO 5500.2W

MCAS Iwakuni Escorted Restricted Area Access Request

C-1

MEMORANDUM

Date: __________

From: ___________________________ ______ ____________ ___________________

Last Name, First Name Rank Unit Work Phone

To: Provost Marshal

Subj: MACAS IWAKUNI ESCORTED RESTRICTED AREA ACCESS REQUEST

Ref: (a) MCO 5530.14A

(b) MCASO 3710.3X

(c) MCASO 5500.2W

(d) Contract Number (CTR Only)

Encl: (1) Appendix E (Escort Privileges Request) for Escort

(2) Location Map with Access Route (CTR Only)

(3) Copies of Worker’s DBIDS Credentials (ALL)

(4) Copies of AVOC License, US/SOFA/Japanese Drivers License and

GME License of Escort (if applicable, with Contractor

Supervisor’s Full Name and Cellphone Number)

1. Per the references, it is requested that the following personnel be authorized escorted access to the indicated restricted area for the performance of their duties from to . Personnel that also require vehicle gate access will receive additional approval with justification written below.

□ FLIGHT LINE □ PORT AREA □ WATER AREA

□ BUILDING# _____________ □ ROOM# _____________

NAME(LAST,FIRST M.) RANK

DODID#

/DBIDS#

ROTATION

DATE/CONTRACT

EXPIRATION

DATE

DD MMM YYYY

ESCORTS NAME

(LAST,FIRST)

ESCORTS

/DBIDS#

AVOC

EXPIRATION

DD MMM YYYY

Note: The individuals listed on this form MUST be ESCORTED into the respective RESTRICTED AREA AT

ALL TIMES and WILL NOT be granted personal access.

APPENDIX C MCASO 5500.2W

MCAS Iwakuni Escorted Restricted Area Access Request

C-2

2. Justification of Esorted Access into a Restricted Area:

3. A copy of this authorization letter must be provided to the PMO

Physical Security Section.

Requester:

Signature Print Name & Date

Requester’s Department Head/Unit CO/Unit XO/Unit SGTMAJ or CIV Equivalent):

Site Security Manager (If Applicable): □ Approved - □ Not Approved □ N/A

Airfield Operations (If Applicable): □ Approved - □ Not Approved □ N/A

Harbor Operations (If Applicable): □ Approved - □ Not Approved □ N/A

Physical Security: □ Approved - □ Not Approved

APPENDIX D MCASO 5500.2W

MCAS Iwakuni Unescorted Restricted Area Access Request

D-1

MEMORANDUM

Date: __________

From: ___________________________ ______ ____________ ___________________

Last Name, First Name Rank Unit Work Phone

To: Provost Marshal

Subj: MCAS IWAKUNI UNESCORTED RESTRICTED AREA ACCESS REQUEST

Ref: (a) MCO 5530.14A

(b) MCASO 3710.3X

(c) MCASO 5500.2W

(d) Contract Number (CTR Only)

Encl: (1) Location Map with Access Route (CTR Only)

(2) Copies of Worker’s DBIDS Credentials (SOFA-CTR Only)

(3) Copies of AVOC License, US/SOFA/Japanese Drivers License and

GME License (if applicable, with Contractor Supervisor’s

Full Name and Cellphone Number) authorized unescorted access to the indicated restricted area for the performance of their duties from to . Personnel that also require vehicle gate access will receive additional approval with justification written below.

□ FLIGHT LINE □ PORT AREA □ WATER AREA

□ BUILDING# _____________ □ ROOM# _____________

NAME (LAST,FIRST M.) RANK

/DBIDS#

ROTATION

DATE/CONTRACT

EXPIRATION

DATE

DD MMM YYYY

AVOC

LICENSE

(YES/NO)

AVOC

EXPIRATION

DD MMM YYYY

Note: This form is for UNESCORTED RESTRICTED AREA ACCESS only, if an individual requires an escort at all times, see Appendix C for “MCAS IWAKUNI ESCORTED RESTRICTED AREA ACCESS REQUEST”.

APPENDIX D MCASO 5500.2W

MCAS Iwakuni Unescorted Restricted Area Access Request

D-2

2. Justification of Unesorted Access into a Restricted Area:

3. A copy of this authorization letter must be provided to the PMO

Physical Security Section.

Requester:

Requester’s Department Head/Unit CO/Unit XO/Unit SGTMAJ or CIV Equivalent):

Site Security Manager (If Applicable): □ Approved - □ Not Approved □ N/A

Airfield Operations (If Applicable): □ Approved - □ Not Approved □ N/A

Harbor Operations (If Applicable): □ Approved - □ Not Approved □ N/A

Physical Security: □ Approved - □ Not Approved

APPENDIX E MCASO 5500.2W

MCAS Iwakuni Escort Privileges Request

E-1

MEMORANDUM Date: _____________

From: _____________ ____________________________ _______________________ Rank/Grade/Position Last name, First name, MI DODID#/DBIDS#

To: Provost Marshal (Attn: PMO Physical Security,Pass and Registration)

Subj: MCAS IWAKUNI ESCORT PRIVILEGES REQUEST

Ref: (a) MCO 5530.14A

(b) MCASO 3710.3X

(c) MCASO 5500.2W

Encl: (1) Background Record Check (if applicable)

(2) AVOC License and GME License (if applicable)

(3) Flightline Regulations Acknowledgement (if applicable) granted escort privileges within the indicated area:

Name:__________________ Rank(if applicable):______ Organization:________

Justification:__________________________________________________________

□ NON-RESTRICTED AREA □ RESTRICTED AREA (NOTE: Include Encl (1),(2),(3))

Date/Time: Start: ______________________ End: _______________________

Requesting Official (*Personnel Authorized by Appendix M):

Requesting Official Print Name Signature Date

Airfield Operations (if applicable): □ Approved □ Not Approved □ N/A

Airfield Operations Print Name Signature Date

Harbor Operations (if applicable): □ Approved □ Not Approved □ N/A

Harbor Operations Print Name Signature Date

Physical Security (PS)/Pass & Registration Office (P&RO):

□ Approved □ Not Approved

PS or P&RO Print Name Signature Date

APPENDIX F MCASO 5500.2W

(SUPPLEMENTAL TO APPENDIX B)

MCAS Iwakuni Outside Authorized Working Hours Request

F-1

(Submit to PMO Pass and Registration Office 5 Business Days in Advance)

MEMORANDUM Date: ______________

DD/MMM/YYYY

From: _______________________________/_______________________/_________________ Requester’s Name Section/Company Name Phone Number *Contract Manager (for contractors) *Section Supervisor (for MLC/IHA)

To: Provost Marshal (Attn: PMO Pass and Registration Office)

Subj: MCAS IWAKUNI OUTSIDE AUTHORIZED WORKING HOURS REQUEST

Ref: (a) MCASO 5500.2W

1. Per the reference, this is a supplemental request to appendix B for the below listed employee to be granted station access to work outside of their original

DBIDS Card/Pass authorized hours. Requestor acknowledges this request deviates from the original employment hours and understand this after hours access authorization will expire on the original contract termination date (as applicable), original issued DBIDS card expiration date or revoke (as appropriate).

□ Copy of original contract, SPOT LOA, or Letter of Employment

□ Schedule of multiple days/time/location – See enclosure (1)

Pass/DBIDS Card#: ___________________________________________________

Name (Last, First): ___________________________________________________

Location of After Hours Work: _________________________________________

Requested Date/Time/Days:

Start: ______________ ____________ End: ______________ _____________ Day (DD/MMM/YYYY) Time Day (DD/MMM/YYYY) Time

Days of Work: Sun, Mon, Tue, Wed, Thu, Fri, Sat

Requester’s Name: *Contract Manager (for contractors) or Section Supervisor (for MLC/IHA):

Contract Manager/Supervisor Print Name Signature Date

Department Head: □ Approved - □ Not Approved

Print Name Signature Date *Personnel Authorized by Appendix M

Provost Marshal or Designee: □ Approved - □ Not Approved

APPENDIX F MCASO 5500.2W

(SUPPLEMENTAL TO APPENDIX B)

MCAS Iwakuni Outside Authorized Working Hours Request

F-2

DBIDS

PASS NO.

LAST NAME FIRST NAME WORK LOCATION START DATE END DATE

START

TIME

END

TIME

NOT VALID WITHOUT PMO STAMP / DATE

APPENDIX G MCASO 5500.2W

MCAS Iwakuni JSDF/Foreign Military Access Request

G-1

PMO

USE ONLY

Received

Date:

Approved

Date:

Tracking#:

1) This visit request should be submitted no later than (10) days prior to the date of the requested visit.

当基地への立入希望者は立入希望日の(10)営業日前迄にこの書類を提出のこと

2) Any visit that contains an O-6 equivalent (or higher), notify the Station CO.

O-6 以上の立入の場合は基地司令に知らせること

3) This form is for Host Nation/Foreign Military personnel visit ONLY.

本立入許可申請書は現役の自衛隊員及び他国の軍人の訓練、演習、岩国基地通過、兵站等の目的の際に利用のこと

1) Purpose of the Visit: 立入目的

2) Access Request Information:立入情報 □ One Day □ Multiple Day

➢ Organization of Guests: ゲスト組織名 Total Number of Guests: ゲスト総数

➢ Required numbers of Escorts: 必要エスコート人数 _______→ PMO USE ONLY PMOにて記入します

Entry Gate:入門

Date:____________ Time:_____________

Exit Gate:出門

Date:____________ Time:_____________

□ Reg size Vehicle and/or Mini Bus ( )台

□ Truck and/or Medium/Large Bus ( )台

□ Aircraft □ Ship/Boat

□ Reg size Vehicle and/or Mini Bus ( )台

□ Truck and/or Medium/Large Bus ( )台

□ Aircraft □ Ship/Boat

Coordinate with PMO Japanese Security Guard (JSG) for any changes on access information no later than one day in advance. 基地への入出門に係る変更は、必ず前日までに PMO警備隊(JSG)と調整して下さい。 JSG Business Hours: Mon-Fri/0800-1600, 253-4849 After Hours/U.S Holidays: 253-3245

➢ What assistance are you requesting and from whom? 岩国基地側へ特に必要な支援等あれば記入のこと

3) Sponsoring Unit/Department POC and Signature :スポンサー部隊・部署情報, 責任者サイン

Unit:部隊名 Section:部署名 POC Name: 担当者氏名 Rank:階級 Phone#:電話番号

Name: 責任者氏名 Rank:階級 Phone#:電話番号 Signature:責任者サイン

MCAS Iwakuni JSDF/Foreign Military Visit Request

G-2

4) Schedule of Visit:スケジュール 全て詳しくご記入下さい。スペースが足りない場合は別紙(G-4)を添付して下さい。

Date Time Location/Bldg# Activity Description

日 時 場所/建物番号 行動内容

5) Special Requirements

A) Flight Line Access □ YES □ NO

Access Hours: - Gate#: Bldg#: / Bldg Name:

Transportation: □ On Foot □ GOV Escort with AVOC:

AVOC EXP Date:

Restriction Code: Control Management Area (CMA)

□ Apron Only □ CMA □ Non-CMA

Station Airfield Operations

□ Concur □ Non-Concur

Print Name/Date:

Signature

B) Port Access □ YES □ NO Restricted Water □ YES □ NO

Access Hours: Bldg#: Bldg Name:

Harbor Operations (Logistics)

□ Concur □ Non-Concur

C) Restricted Area Access □ YES □ NO

PMO Physical Security

□ Concur □ Non-Concur

D) Photo Equipment □ YES □ NO (Photo Req# )

Security Management Office

□ Concur □ Non-Concur

Provost Marshal’s Approval

□ Approved □ Disapproved Print Name/Date:

G-3

Tracking# __________

Name of Escort: ____________________ Grade: _______ Unit Name: _________________

TEL#: ___________ __________________ Lodging(宿泊): N/A なし / On Base / Off Base Work Cell Phone (Circle one of above) 宿泊があればいずれかを選択

From: ____________ ____________ To: ____________ ____________ Time Date Time Date

*** Everything except the address needs to be in both Japanese and English 住所以外は全て日本後、英語で記入のこと

PRINT NAME（氏名-漢字+ローマ字）

PRESENT ADDRESS (現住所)

MILITARY ID UNIT

NAME

部隊名

部署名

RANK

TITLE

階級

DOB(生年月日-西暦)/AGE(歳)

TYPE OF ID

COUNTRY OF CITIZENSHIP (国籍) PHONE# (電話番号)

( )Page / Total ( )Pages

G-4

Schedule スケジュール 別紙

---Time/時間 -Location/場所 - Activity Details/詳細

APPENDIX H MCASO 5500.2W

MCAS Iwakuni Official Visit/Business Access Request

H-1

** This Access Request is only for short term (1-7 days).

** You must submit this request at least 3 business days in advance to PMO.

** Restricted Area Access Request requires Appendix C or D submitted to PMO Physical Security.

** Guest(s) must be escorted at all times.

Name of Sponsor: ____________________ Grade: __________ DoD ID#: ________________

Organization/Unit: __________________ TEL: ________________ _____________________ Work Phone Cell Phone

Name of Escort: ___________________ Grade: __________ DoD ID#: ________________

From: ________ ________ To: ________ ________ Sponsor Email: ____________________________ Time Date Time Date

Destination:____________________ Business Purpose:_______________________________ **国籍が日米以外のゲストはパスポートの写真のページを添付/ If guest is not a Japanese or US citizen, a passport copy of the photo page is required

PRINT NAME（氏名-漢字+ローマ字）

NATIONALITY

(国籍) HOME ADDRESS (住所) COMPANY

NAME

会社名

VEHICLE

車両番号

PMO

DOB(生年月日-西暦)/AGE(歳) *ID#

(read below) PHONE# (電話番号)

1) Your respective guest(s) must check in upon entering the installation and be issued a DBIDS pass. A *valid picture ID is required at the Gate when checking in. (*ID - Passport, Residence Card, Work Visa, Driver’s License (JN only) - pls ask PMO all other IDs) 2) DBIDS Passes must be returned to the Gate Sentry when your guest(s) exit the installation.3) A violation of this authorization may result in disciplinary action up to termination of sponsorship privileges.

PMO Approving Official

Sponsor Signature Print Name

APPENDIX I MCASO 5500.2W

MCAS Iwakuni Sample Letter of DTCN Access Request

I-1

From: Sponsor of the DTCN Visitor(s), Organization

To: Commanding Officer, Marine Corps Air Station Iwakuni

Via: (1) Supervisor/Officer-In-Charge, Sponsoring Organization

(2) Commanding Officer, Sponsoring Organization

(3) Provost Marshal

Subj: MCAS IWAKUNI DESIGNATED THIRD COUNTRY NATIONALS (DTCN) ACCESS REQUEST

Encl: (1) Personal Visitor Request(APPENDIX K) or DBIDS Access

Authorization Request (APPENDIX B)

(2) Visitor Information

(3) Copy of Applicant’s Foreign Passport(s)-All Pages (color)

(4) Proof of Familyship (for personal visitation only)

(5) Letter of Employment (for contractor only)

(6) Personal History Statement (for contractor only)

(7) Copy of Applicant’s Residence Card, Special Permanent

Resident Certificate (if applicable)

1. Access is requested for the following individuals as below:

Name of Visitor Country Relationship to the Sponsor

(Last, First Middle) (or Company Name) a.------------------- --------------- ---------------------b.------------------- --------------- ---------------------c.------------------- --------------- ---------------------

• Dates: (01 JAN 20xx – 31 JAN 20xx), xx days

• Days of the Week: (Mon, Fri or Mon-Fri) --→ For Contractor only

• Hours: (0600-1800, 0400-2400) --→ For Contractor only

• Contract Number: _______________________ --→ For Contractor only

• Purpose of access:

(Please specify what type of job and location of job)

2. The point of contact for this request is Mr. J. P. Smith at john.smith@anywhere.com or 645-####/090-xxx-xxxx.

Sponsor’s Signature

APPENDIX I MCASO 5500.2W

MCAS Iwakuni Sample Letter of DTCN Access Request

I-2

Date: ____________

From: Supervisor/Officer-In-Charge, Sponsoring Organization

Via: (1)Commanding Officer, Sponsoring Organization

(2)Provost Marshal

1. Forwarded, recommending approval/disapproval.

Print Name Signature

SECOND ENDORSEMENT Date: ____________

From: Commanding Officer, Sponsoring Organization

Via: Provost Marshal

THIRD ENDORSEMENT Date: ____________

From: Provost Marshal

FINAL DECISION Date: ____________

From: Commanding Officer, Marine Corps Air Station Iwakuni

To: Sponsor of the DTCN Visitor(s), Organization

______ APPROVED/ ______ DISAPPROVED

Comments:

APPENDIX J MCASO 5500.2W

MCAS Iwakuni Parental Permission Statement

J-1

I (Parent) authorize my child to visit MCAS Iwakuni written as below.

私は私の子供が下記の内容で岩国基地に滞在する事に同意します。

CHILDS NAME (LAST, FIRST, MIDDLE)

子供の名前(漢字) /(ローマ字)

DATE OF BIRTH (DD/MMM/YYYY)

子供の生年月日

AGE

年齢

DATE OF VISIT

入門希望日

TIME OF VISIT

入門希望時間

PURPOSE OF VISIT

入門目的 or 参加イベント名

DESTINATION

目的地

PARENT ADDRESS/PHONE NUMBER

親の住所

親の電話番号 （ ） -

PARENT NAME/SIGNATURE

親の氏名・漢字 / ローマ字 (自署で記入)

**This original parental permission statement must be submitted to PMO with the “Personal Visitor

Request (APPENDIX K)” prior to visitation date.

この承諾書の原本は”Personal Visitor Access Request (APPENDIX K)”と共に希望する入門日の前日までに PMO へ提出して下さい。

Sponsor Input:スポンサー記入欄

Sponsor Name:(スポンサー氏名) Unit/Org Name:(所属組織) Cell Phone#:(携帯番号)

Signature of Sponsor(スポンサーのサイン): __________________________________

SAMPLE(承諾書 記入例）

I (Parent) authorize my child to visit MCAS Iwakuni written as below.

私は私の子供が下記の内容で岩国基地に滞在する事に同意します。

CHILDS NAME (LAST, FIRST, MIDDLE)

子供の名前(漢字) /(ローマ字)

岩国 次郎 / IWAKUNI, Jiro

DATE OF BIRTH (DD/MMM/YYYY)

子供の生年月日

31 / Dec / 20xx

AGE

年齢

DATE OF VISIT

入門希望日

31 / Dec / 20xx

TIME OF VISIT

入門希望時間

10:00 ～ 16:00

PURPOSE OF VISIT

入門目的 or 参加イベント名

Visiting friend/Halloween etc.

DESTINATION

目的地

Food Court

PARENT ADDRESS/PHONE NUMBER

親の住所

岩国市三角町 1-X-X

親の携帯番号 080-xxxx-xxxx

PARENT NAME/SIGNATURE

親の氏名・漢字 / ローマ字 (自署で記入)

岩国 太郎/ IWAKUNI, Taro **This original parental permission statement must be submitted to PMO with the “Personal Visitor

Request (APPENDIX K)” prior to visitation date.

この承諾書の原本は”Personal Visitor Access Request (APPENDIX K)”と共に希望する入門日の前日までに PMO へ提出して下さい。

Sponsor Input:スポンサー記入欄

Sponsor Name:(スポンサー氏名) Unit/Org Name:(所属組織) Cell Phone#:(携帯番号)

John Doe PMO,H&H 090-xxxx-xxxx XXXX

Signature of Sponsor(スポンサーのサイン): _________John Doe_________

親御さんはこの青枠内の部分をご記入下さい

APPENDIX K MCASO 5500.2W

MCAS Iwakuni Personal Visitor Access Request

K-1

MUST SUBMIT TO PMO 10 BUSINESS DAYS IN ADVANCE (1-DAY/EXTENDED/COMREL Event)

Name of Sponsor: ____________________ Grade: __________ DoD ID#: ________________

Organization/Unit: __________________ TEL#: __________________ __________________ Cell Phone Work

Email: ______________________________ QTRS#:___________ Purpose:_____________________________

Name of Escort: _____________________ Grade:___________ DoD ID#: ________________

From: _________ _________ To: _________ _________ ( )days VEH:_____________ Time Date Time Date Number of Vehicles

**17 歳以下で親の同伴がない場合は承諾書が必要/ Children 17 years old or younger traveling without their parents need to attach signed Parental Statement.

**国籍が日米以外のゲストはパスポートの写真のページを添付/ If guest is not a Japanese or US citizen, a passport copy of the photo page is required **ID# for Japanese National(JN) – Passport, Driver’s License, Health Insurance Card - pls ask PMO for all other IDs

PRINT NAME OF GUEST（氏名） COUNTRY OF CITIZENSHIP (国籍)

HOME ADDRESS (現住所)

TEL# (電話番号)

Passport# (For JN, See above Other Acceptable IDs)

RELATION

TO SPONSOR

PMO Input

Escort Required DOB(生年月日)DD/MMM/YYYY,AGE(歳)

I have read and understood the PRIVACY ACT STATEMENT and Escort Policy and will comply as required.(on 2nd page)

Sponsor's Signature LODGING ENDORSEMENT REQUIRED PMO Approving Official

FOR EXTENDED PASS

ON THE BACK SIDE

PRINT NAME CUI PRINT NAME

MCAS Iwakuni Personal Visitor Access Request

K-2

PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. 301; 10 U.S.C. 5031; 44 U.S.C. 3103 AND EO 9397

PRINCIPAL PURPOSE: Used to record information and details of criminal activity which may require investigative action by commanding officers, supervisors, NCIS, etc. Used to provide information to the appropriate individuals within DoD organizations who ensure that proper legal and administrative action is taken.

ROUTINE USES: Information may be disclosed to local, county, state, and federal law enforcement or investigatory authorities for investigation and possible criminal or civil court action. Information extracted from this form may be used in other related criminal and/or civil proceedings.

DISCLOSURE: Voluntary. Information is used to positively identify the individual making the statement and to check past criminal activity records. Failure to disclose any information may result in delay of processing.

1) I UNDERSTAND THAT MY GUEST(S) MUST BE ESCORTED AT ALL TIMES WHILE ON THE INSTALLATION UNLESS

OTHERWISE SPECIFIED.

2) My guest(s) must check in at the Main Gate Visitor Center prior to entering the installation and be issued a DBIDS pass. A valid photo I.D., proof of citizenship, and proof of legal entry into Japan are required.

3) Facility access by my guest(s) is contingent upon individual facility policies and should be addressed with each facility directly.

4) 1-day visitors are approved to be signed-on and access MCAS Iwakuni between 0600 and 2359 daily, unless otherwise authorized. All 1-day visitors must depart the installation prior to 0030 unless otherwise authorized.

5) As the sponsor of my guest(s), I assume responsibility for their conduct and/or misconduct and/or any damages incurred while aboard the installation due to their conduct as well as ensuring their proper use of MCAS Iwakuni facilities. I will ensure my guest(s) are familiar with applicable military and Japanese laws that govern their conduct. Further, I understand that my guest(s) do not possess SOFA status and are responsible for meeting/maintaining Visa requirements.

6) In case my guest(s) needs to extend their stay (over 30 days in TLF/Kintai, 90 days in on-base Housing), an extension request (page K-3, K-4) must be submitted 14 business days in advance of the pass expiration date to be approved by the CO, MCAS Iwakuni. This form can be picked up at PMO.

7) A violation of this authorization may result in disciplinary action up to termination of sponsorship privileges.

8) I understand that I must provide a legible passport copy of the photo page of any guest(s) who holds a passport in a country other than the U.S. or Japan, who are not a Designated Third Country National (DTCN). DTCN guest(s) require prior approval from the MCAS Iwakuni Commanding Officer.

**For a list of DTCN countries, and for access requirements for DTNC guest(s), please contact PMO.

LODGING INFORMATION & ENDORSEMENT REQUIRED FOR EXTENDED PASS

I REQUEST MY GUEST(S) BE AUTHORIZED TO STAY AT (CHECK APPROPRIATE BOX):

□ FAMILY HOUSING □ BACHELOR HOUSING □ TLF/ □KINTAI INN

MAIN/ATAGO BLDG&RM#: BLDG&RM#: ROOM#

It is not authorized to request extended visitation pass for guests staying off-base. Sponsors are required to register their guests at the visitor center at the Main Gate or Atago Gate for every day of access.

Housing Signature BOQ/BEQ Signature TLF/Kintai Inn Signature

PRINT NAME PRINT NAME PRINT NAME

K-3

MCAS Iwakuni Personal Visitor Access Request (Extension)

Date:__________

From: ______________________________________________________ (Sponsor’s Rank, Name, EDIPI/MOS, Unit/Dept)

Via: (1) Requester’s Unit/Dept. Commanding Officer

(2) Military Family Housing (or TLF, Kintai Inn, BEQ/BOQ)

(3) Facilities Officer (*required only when guest(s) staying in Housing)

(4) Provost Marshal Office

Subj: REQUEST FOR EXCEPTION TO POLICY (ETP) FOR EXTENSION OF

PERSONAL VISITOR ACCESS OVER 30/90 DAYS

Encl: (1) Current DBIDS Paper Pass

(2) MCAS Iwakuni Personal Visitor Request (APPENDIX K)

(3) Copy of Passport (proof of extension by JN immigration)

1. I would like to request an ETP for the Installation Access as follows:

a. Visitor’s Name: _______________________________________

b. Relationship to the Sponsor: __________________________

c. Current DBIDS Pass: from _______ to ________ (_____) days

d. Extension Period: from _______ to ________ (_____) days

e. Housing Address: ______________________________________

f. Justification: ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

2. POC: (e-mail)________________________ or DSN _____________

Sponsor’s Signature

FIRST ENDORSEMENT Date: ____________

From: Requester’s Unit/Dept. Commanding Officer

Via: (1) Military Family Housing

(2) Facilities Officer

(3) Provost Marshal

1. Forwarded, recommending □ approval/ □ disapproval.

MCAS Iwakuni Personal Visitor Access Request (Extension)

K-4

SECOND ENDORSEMENT Date: ____________

From: Military Family Housing (or TLF, Kintai Inn, BEQ/BOQ) To: Commanding Officer, Marine Corps Air Station Iwakuni Via: (1)Facilities Officer (if applicable) (2)Provost Marshal

THIRD ENDORSEMENT Date: ____________

From: Facilities Officer (*required only when guest(s) staying in Housing)

Via: Provost Marshal

FOURTH ENDORSEMENT Date: ____________

From: Provost Marshal

FINAL DECISION Date: ____________

From: Commanding Officer, Marine Corps Air Station Iwakuni

To: _________________________________________________ Sponsor’s Rank, Name, EDIPI/MOS, Unit/Dept

______ APPROVED/ ______ DISAPPROVED

Comments:_______________________________________________________

APPENDIX L MCASO 5500.2W

MCAS Iwakuni Report/Request for Reissuance/Termination of

Lost/Stolen DBIDS Credential

L-1

MEMORANDUM Date_______________

From: _______________________________ (Name of Requester)

_______________________________ (Name of Unit/Organization/Company)

To: Supervisor, Pass and Registration Office

Via: _______________________________ (Sponsoring Unit/Organization of MCASI)

Subj: MCAS IWAKUNI REPORT/REQUEST FOR REISSUANCE/TERMINATION OF LOST/STOLEN

DBIDS CREDENTIAL

Ref: (a) MCASO 5500.2W

1. It is requested that the following pass be reissued/terminated:

a. Contract number/activity employed in: ___________________________________

b. Name of employee: _______________________________________________________

c. Lost pass number/Total count of lost: __________________/_________time(s)

d. Circumstances concerning the lost pass: _________________________________

e. A diligent search has been made to recover the lost pass.

Requester Print Requester Signature Date

FIRST ENDORSEMENT

From: ___________________________ (Name of Depertment Head)*Personnel Authorized by Appendixv M

___________________________ (Name of sponsoring Unit/Organization of MCASI)

To: Supervisor, Pass and Registration Office

1. Forwarded for action.

Depertment Head Print Depertment Head Signature Date

ACKNOWLEDGMENT

P&RO Print P&RO Signature Date

APPENDIX M MCASO 5500.2W

MCAS Iwakuni Statement of Understanding for Official Signers

M-1

Date:_____________

I _______________________ (Requester’s Name) acknowledge the following:

1. Only MCAS Iwakuni (MCASI) Departments Heads, MCASI Tenant Commanders or the Officers-In-Charge (OICs) of detachments or other organizations permanently assigned to MCASI may sign Appendix B, E, F, L, N of MCASO 5500.2W for an individual to receive access to MCASI. If the Department Head, Tenant Commander, or OIC is unavailable due to TAD or leave, the respective Deputy Department Head, Acting Commander, or Acting OIC may sign such a request once he or she signs a copy of this form and receive Station CO/XO’s approval. This authority cannot be further delegated unless approved by the CO/XO, MCASI.

2. By signing a request for an individual to receive a DBIDS credential or other access request to enter MCASI, I am certifying that the individual has a legitimate reason for gaining access to MCASI in an official or professional capacity that contributes to the success of MCASI. I will not sign a request that involves VIPs (O-6 or civilian equivalent or above), members of the media, or an individual desiring to enter MCASI for a personal visit. VIPs and Media personnel, whether for a personal or official visit, require the approval of the CO/XO, MCASI. If in doubt as to whether someone has a need to access MCAS Iwakuni, consult with the Provost Marshal or the CO/XO, MCASI.

3. The failure to properly certify whether a person has a need to access MCAS Iwakuni, or the failure to follow the requirements of this statement of understanding may result in prosecution under the Uniform Code of Military Justice or other adverse action. Violations of this Order by members of the civilian component or dependents may result in appropriate administrative remedies.

Once this request has been approved, the approved letter needs to be submitted to PMO Pass and Registration Office by the requesting organization.

4. This authorization letter is effective for 24 months from the date signed. If an extension is required, the requester will coordinate with the Station Adjutant Office prior to its expiration otherwise a new request must be submitted.

5. Justification for this request is as below:

6. The point of contact for this request is (Requesting Department’s OIC):

OIC Name Unit/Dept./Section Rank/Title DSN

Requester’s Signature Requester’s Print Name Rank/Title Service

MCASI CO/XO: □ Approved - □ Not Approved

APPENDIX N MCASO 5500.2W

MCAS Iwakuni Inactive DBIDS Credential Activation Request

N-1

Date:_______________

From: (Requester’s Name) __________________________________________

Unit/Dept: _______________________ Phone#: ___________________

To: Pass and Registration Office, Provost Marshal Office

Request Visit Date/time Date (dd/MMM/yyyy) Time

Purpose of Visit (in detail):

Visitor’s Info

Name Title Employer DBIDS#

Section Name or Individual for the Visit:

Bldg Name: Bldg#:

MCASI POC info:

Name Work Section Phone#

** Restricted Area Access is required Appendix C or D separately.

I have read and understood the content of MCASI Order 5500.2W and will comply as required.

Requester (Authorized by Appendix M):

Print Name

Signature: Date:(dd-MMM-yyyy)

PMO Official:

Print Name

Signature: Date:(dd-MMM-yyyy)