ESBD_401277_1748872677255_ATB408~1.PDF

FROM:

PERSONAL EMAIL (Approved passes will be emailed):

SPONSOR DoD-ID NUMBER:

BADGE NUMBER: DATE ISSUED: EXPIRATION DATE:

SIGNATURE OF BADGE ISSUING OFFICIAL:

CELL PHONE#:

DAYS OF WEEK GRANTED TO VISIT/WORK MON TUE WED THU FRI SAT SUN

DATES OF PASS:

VISITOR or CONTRACTOR PASS REQUEST

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C 8013 and Executive Order 9397 (SSN), as amended.

PURPOSE: To request and record the issuance of visitor & contractor identification badges for Ellington Field JRB.

ROUTINE USE: DOD "Blanket Routine Uses" apply; SSN will be used to conduct a criminal background investigation through law enforcement.

DISCLOSURE: VOLUNTARY. Failure to provide the requested information will result in non-issuance of the pass.

SECTION III: Ellington Field JRB SPONSOR (Completed by Base Sponsoring Official)

LICENSE PLATE #:

PRIVATE

COMPANY

POLICY EFFECTIVE DATE:

POLICY EXPIRATION DATE:

VEHICLE MAKE:

NOTICE: While on this Installation, all personnel and property are subject to search.

Controlled radioactive or explosive materials being brought onto Ellington Field JRB must first be approved by the 147 ATKW Safety Office.

147 ATKW FORM 17, 01 October 2023

SECTION II: VISITOR or CONTRACTOR VEHICLE INFORMATION

This section applies to visitors and contractors with a need to operate motor vehicles on the installation.

NOTE: Vehicle owner must maintain current state certificate of registration and inspection for the vehicle operated.

SPONSOR SIGNATURE:

YEAR: MODEL: COLOR:

I certify that the applicant has an official/ authorized need for the visitor/contractor pass and has been briefed on its proper use.

EMAIL: BUSINESS ADDRESS OR MILITARY ORGANIZATION OF SPONSOR:

INSURANCE COMPANY NAME AND PHONE NUMBER:

SECTION I: VISITOR or CONTRACTOR INFORMATION

HOME ADDRESS: PHONE:

DL# and State:

CITIZEN: (Country)DATE OF BIRTH: SOCIAL SECURITY #

VISITOR/CONTRACTOR NAME: (Last, First, MI)

PRIVACY ACT INFORMATION: The information in this form is CONTROLLED UNCLASSIFIED INFORMATION. Protect IAW the Privacy Act of 1974

Applicant MUST provide high resolution photo of driver's license with this application.

SPONSOR NAME: (Last, First, MI):

COMPANY NAME: (If contractor)

STATE:

SECTION IV: Security (To be completed by Badge Issuing Official)

BACKGROUND CHECK DATE: DENIED: PENDING APPROVAL:

Email form & photograph of drivers license to:

147.ATKW.SFS.CC.STAFF.Org@us.af.mil

TO:

PURPOSE OF VISIT & LOCATIONS OF VISIT / WORK: HOURS OF PASS:

FROM: TO:

APPROVED:

1399779142N Highlight