Exhibit 12 - Contractor AIE Long Term Badge Application.pdf

AIE LONG TERM BADGE REQUEST FORM (Contractor/Vendor) All requests for an AIE Long Term Badge must be endorsed by the Government Agent responsible for oversight of the Contract.

Companies must be listed on the Contractor Authorization List (CAL) maintained by the Directorate of Emergency Services.

TO BE COMPLETED BY VEHICLE REGISTRATION:

See Reverse for list of documents and information required to be provided when reporting to have a pass issued.

TO BE COMPLETED BY APPLICANT (write legibly and in English):

NAME: _____________________________ ___________________ ______ _____

LAST First Middle Suffix

Date of Birth: ____/_____/____ (Year – Month – Day)

Place of Birth: _______________________ ________ _____________________________ City State Country (if not US)

Driver’s License Number: __________________________ State: _______ Expiration Date: ___________ (A person living and working in WA should generally have a WA DL.

Non-US Citizen Certification:

Passport Number: _________________________ Country: _____________

VISA Entry & Expiration Dates: ____________________________

Alien Registration Number (A#) _____________________________

APPLICANT SIGNATURE: ________________________________________________________

TO BE COMPLETED BY EMPLOYER / CAL POC (write legibly and in English):

Company/Organization Name: ______________________________________________________

POC Name: _______________________ POC Telephone Number: _____________

POC JBLM Location: Bldg. No. ___________ Room No. ________________

LENGTH OF PASS REQUEST, (not to exceed 12 months): _______________

DAYS OF WEEK / HOURS ACCESS REQUIRED: ________________________________

EMPLOYER POC SIGNATURE: ________________________________________________________

TO BE COMPLETED BY GOVERNMENT AGENT (write legibly and in English):

Government POC Name: _______________________ POC Telephone Number: _____________

ORGANIZATION/AGENCY: ________________________ Phone #. ________________

Contract # ________________________________________ Contract Base Expiration Date: _________

GOVERNMENT POC SIGNATURE: ________________________________________________

NOTE: The Company POC is required to notify the Registration Office at Waller Hall if the recipient of the badge is no longer eligible to possess a badge. When possible the POC should retrieve the badge and return it to a Visitor Center.

ACCEPTABLE IDENTITY VERIFICATION DOCUMENTS FOR PRESENTATION WITH WASHINGTON

LICENSE OR WASHINGTON ID CARD

ANY ONE OF THE DOCUMENTS BELOW Employee ID Card issued by a federal, state or local

DOD CAC card government agency provided it contains a photograph and biometric information such as:

Name, DOB, Gender, Height, Eye Color, and or/ Address.

DOD Uniformed Services Identification Privilege Card

US PASSPORT/PASSPORT CARD

VA Issued Health Card U.S. Coast Guard Merchant Mariner Card

Permanent resident card or Alien Registration Receipt card (INS Form I-551)

Transportation Worker ID Card (TWIC) issued by DHS

Native American tribal document

Foreign passport w/ 1-551 stamp or temp 1-551 printed notation on a machine readable immigration Visa

U.S. Government Issued, authenticated Fed PIV

For personnel 17 and under, a school ID with a photograph

Foreign passport w/ a current arrival-departure record or foreign passport with INS Form 1-94/I-94A matching the Passport and containing an endorsement of the nonimmigrant status, authorizes the alien to work for an employer in the USA.

U.S. Military or Draft Record containing name and DOB

Washington State Enhanced Drivers License or Enhanced

WA ID

Washington State Commercial Drivers License or CDL

US Refugee Travel Document I-327 and I-571 issued by

NOTE:

1. ALL persons requesting a pass will be subject to security vetting. Vetting will include a criminal history background check. Persons who do not pass the security vetting will be denied access and provided with the process for submitting an appeal. The appeal process is governed by Army Directive 2014-05 and is non-Waiverable. The appeal process can take an extended period of time.

2. Visitor Center staff will contact a Company POC listed on the CAL to verify that the request for a pass is valid.

3. All information on the reverse side of this form must be completed. The completed form and the verification documents listed above are to be presented to Visitor Center Staff

4. Any conduct which is detrimental to the maintenance of good order and discipline on the Joint Base Lewis-McChord Military Installation may result in confiscation of the IAC, immediate removal from the installation, and the imposition of a BAR.

5. The Government Agent has overall responsibility for the conduct of the pass holder at all times while they are on the JBLM Military Reservation. While this does not include punitive liability, the Agent may be required to brief senior installation leaders regarding acts of employee misconduct.

6. The AIE badge will be issued based off of the active contract company, listed on the Contract Authorization List (CAL). The use of this badge will only be used in support of that contract, no other use of this badge is authorized, and unauthorized use of AIE badges will be confiscated by security personnel.

7. Pass holders will confine themselves only to those areas related to issuance of the pass. Pass holders will not enter any marked, restricted and/or controlled areas. Specifically airfields, command headquarters, motor pools, military training facilities, military barracks, housing areas other than those where you are an invited guest, areas where military weapons are present, fire stations, and communications facilities Be prepared to identify yourself and the purpose of your presence on JBLM to military security personnel at all times.

8. Your signature on this document is consent to search your vehicle and packages at any time while on the installation.

9. Firearms and other personal weapons are prohibited except for specific sporting activities.

10. Any firearm brought onto JBLM property for a legitimate activity is required to be registered with the Provost Marshal.

11. Concealed weapons permits are not valid on JBLM.