ESBD_452864_1774291105912_ATTACHMENT G.Y - Ellington AFB (EF) Form 17 - Visitor Contractor Pass Request (05OCT25).pdf

UNESCORTED ACCESS REQUEST

147 ATKW FORM 17 20250405 PREVIOUS EDITIONS ARE OBSOLETE

The following information has been provided to aid in the completion of the Unescorted Access Request.

SECTION I: SPONSOR INFORMATION

Block 1. Title (Insert sponsor's title i.e., Mr., Ms., Mrs., or associated rank of Military/GS employee) Block 2. Last Name, First Name, MI (Full name of sponsor, use format assigned) Block 3. Duty Phone (Office number you can be reached at during business hours) Block 4. Cell Phone (Phone number you may be reached at during requested access times for your guests) Block 5. DoD ID Number (Assigned number on your DoD ID Card-This is required to fully identify you in DBIDS) Block 6. Organization/Home Address (If sponsoring for official government business use your organization. If sponsoring for personal purpose use your home address Block 7. Email Address (Email submissions will be sent encrypted using an official .mil email address)

SECTION II: ACCESS DETAILS

Block 8. Category for Access (Check the category of your guest).

Block 9 Location (Select EFJRB location(s) for guests access. The guest must have a valid need for entry.

Block 10. Time Frame

From Date (Start date of visit/contract) To Date (End date of visit/contract)

From Time (Start time of visit or start time each day for continual access) To Time (End time of visit or end time each day for continual access)

Days of Week (Days of week entry is required. For visits, select day[s] visit will take place. For continual access, provide week days required for work)

Block 11. Reason for Access. Provide detailed justification for access (i.e., Meeting, Tow Truck, Pop-A-Lock, Taxi, Promotion Ceremony, Family visit, etc…).

Block 12. Contracted Company Sponsored or Special Event Name (Identify the visiting organization, name of event, or contractor company name to include information as prime or sub contractor and contract period)

Block 13a. Date of Signature (As described) Block 13b. Name, Grade/Rank, Office Symbol, and Title of Sponsor (As described) Block 13c. Signature (Signed by sponsor)

SECTION III: Visitor Center Use Only.

SECTION IV: Guest Information.

Block 15. Enter information for all persons 18 years of age or older.

• Last Name, First Name MI (Full name of visitor, use format assigned)

• DOB (Date of birth in the format of DD/MM/YYYY)

• Country (Country of birth for foreign visitors)

• ID Type (Select appropriate drop-down option) **Note: See below for acceptable ID forms.**

REAL ID Driver's License

Passport/Visa

REAL ID State Identification Card

Permanent Residence Card

• ID Number (The associated number assigned to the ID Type)

• Country of Issue (Country where identification was issued)

• State of Issue (State where identification was issued)

• Social Security Number (As described)

AUTHORITY: Title 10, United States Code 8012.

PRINCIPAL PURPOSE: To assist security personnel in establishing a fitness determination through the identity proofing and vetting process.

ROUTINE USES: To be used by personnel requesting to obtain guest installation access pass for unescorted access to Ellington Field Joint Reserve Base (EFJRB) installation for 1-30 days, for special one-time events or contractors requiring access for the entirety of their contract.

DISCLOSURE: Disclosure of the requested information is voluntary; however, failure to provide information may result in access denial to EFJRB Installation by the Security Forces Squadron, Installation Access Control Section.

SPONSORS: Email completed form to the following organizational inbox address from an official .mil address:

147.atkw.sfs.cc.staff.org@us.af.mil. See page 4 for the list of disqualifications for entry. Note: Any request submitted by anyone other than the sponsor will not be processed.

GUESTS: Once notified by the sponsor of a confirmed satisfactory background check, pass/badge appointments may be scheduled at:

https://outlook-dod.office365.us/owa/calendar/JointBaseEllingtonFieldVisitorControlCenter@bookings.af.mil/bookings/

PRIVACY ACT INFORMATION: The information in this form is CONTROLLED UNCLASSIFIED INFORMATION that must be protected in accordance with the Privacy Act of 1974.

**Note: visitors under the age of 18 will require escort by a DoD credentialed person if not being issued a visitor pass.**

PREVIOUS EDITIONS ARE OBSOLETE

III. VISITOR CENTER USE ONLY

I. SPONSOR INFORMATION

1. TITLE 2. LAST NAME, FIRST NAME, MI 3. DUTY PHONE 4. CELL PHONE NUMBER 5. DOD ID NUMBER

6. ORGANIZATION/HOME ADDRESS 7. EMAIL ADDRESS

II. ACCESS DETAILS

8. CATEGORY OF ACCESS 9. LOCATION 10. TIME FRAME

FAA

ONEWEB

BLDG ______

BASEWIDE

BASE EXCHANGE

From Date:

To Date:

From Time:

To Time:

Thursday

Wednesday

Sunday

Monday

Tuesday

Saturday

Friday

11. REASON FOR ACCESS (Be Specific)

14a. RECEIVED DATE

14b. VETTED DATE

14c. DATE ISSUED

TSDB

NCIC III AFJIS

12. CONTRACTED COMPANY SPONSORED OR SPECIAL EVENT NAME

13b. NAME, GRADE/RANK, OFFICE SYMBOL, AND TITLE OF SPONSOR 13c. SIGNATURE

14g. NAME, GRADE/RANK, OFFICE SYMBOL, AND TITLE OF VERIFIER 14h. SIGNATURE

13a. DATE OF SIGNATURE

14f. DATE OF SIGNATURE

147 ATKW FORM 17 20250405

14d. BADGE NUMBER (DBIDS)

APPROVED

DENIED

Contractor/Vendor

DoD Auxiliary (Civil Air Patrol, USCG Auxiliary,US Naval Cadet Corps)

Delivery/Pick-Up

Visitor/Volunteer

Special Event

NOSC ID Appt

PRIVACY ACT INFORMATION: The information in this form is CONTROLLED UNCLASSIFIED INFORMATION that must be protected in accordance with the Privacy Act of 1974.

147 ATKW FORM 17 20250405 PREVIOUS EDITIONS ARE OBSOLETE

IV. GUEST INFORMATION.

15. Enter information for all persons 18 years of age or older.

DATE RECEIVED

Last Name, First Name, MI DOB

(DD/MM/YYYY)

Country of Birth

ID

Type

ID

Number

Country of Issue

State of

Issue Social Security Number

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Sponsor Name:

DODI:

PRIVACY ACT INFORMATION: The information in this form is CONTROLLED UNCLASSIFIED INFORMATION that must be protected in accordance with the Privacy Act of 1974.

Ellington Field JRB Disqualifications for Entry (Applicable to non-DoD ID visitors & contractors)

Current a/o 30Oct24

Offense Category From conviction *Behavior and/or criminal record posing unacceptable risk to Installation and/or personnel (History of multiple crimes in this list)[147SFS/S3O will make determination of fitness]

Indefinite

*Charges pending hearing Denied until closed *Previously barred from federal installation or stand-alone facility Indefinite *Terrorist Watch List (federal or state) for criminal or terrorist activity Indefinite *Unable to verify identity Until properly ID’d Active wants/warrants Until cleared Aiding and abetting a criminal 5 years Aiding prisoner to escape Indefinite Aiding enemies of the U.S. Indefinite Aggravated assault (LE, serious bodily injury, w/deadly weapon) 10 years Assault (simple) and/or battery 1 year Child: abuse/endangerment/sex assault/pornography Indefinite Counterfeiting/forgery 5 years Criminal possession of a weapon (Non-firearm) 5 years Drugs: manufacture/possess to sell/distribution 10 years Drugs: possession/use 1 year Espionage Indefinite Firearm charges (federal & state) Indefinite Gang affiliation Indefinite Hacking Indefinite Homicide (murder) Indefinite Kidnapping/abduction Indefinite Manslaughter 10 years Probation/parole (non-traffic) Until served Sex offense, 1st degree Indefinite Sex offense, 2nd degree 10 years Sex offense, 3rd degree 5 years Sex offense, 4th degree 1 year THEFTS- ALL 3 years Human Trafficking and/or Prostitution Indefinite Violent Crimes: Arson, Bombing, Terrorism (including bomb threats) Indefinite

147 ATKW Form 17_PG 3

14h: