Exhibit B - ASG-KU DES Form 190-16.01 Access Application.pdf

39. Name of Primary Contract Company Representative:

31. Project Name/Task Order:

33. Supervisor Work Number:

38. Primary Contract Contact Information::

40. Signature of Primary Contract Company Representative:

42. Subcontract Number:

35. Contract Expiration Dates (dd/mmm/yy) 36.Contract Period (Base plus option years):

41. Subcontract Company Name:

24. 26.

SECTION III - Company/Contract Information

28. Primary Camp / Work Location of Employee: 29. Department and Section:

9. Gender: 10. Eye Color: 11. Hair Color: 22. Work Phone Number: 23. DSN Phone Number:

30. Unit / Employer:

32. Supervisors Name:

34. US Military Contract Number:

37. Primary Contract Company:

ASG-KU ACCESS APPLICATION

Data Required by the Privacy Act of 1974 (5 USC 552a), DOD Directive 5400.11-R, 10 USC 3013, 10 USC 5013, 10 USC 8013 and Executive Order 9397

AUTHORITY: 10 U.S.C. 113, Secretary of Defense, Note (Use of Smart Card Technology in the Department of Defense); Directive-Type Memorandum (DTM) 09-012, Interim Policy Guidance for DoD Physical Access Control; 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; DoD Directive 1000.25, DoD Personnel Identity Protection (PIP) Program; DoD Instruction 5200.08, Security of DoD Installations and Resources; DoD 5200.08-R, Physical Security Program; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): The records support DoD physical security and information assurance programs, to issue individual facility/installation access credentials, and for identity verification purposes. The system also is used to record personal vehicles and property registered with the DoD and for producing facility management reports. The records may be accessed by other physical access control systems for further verification at other sites. Records may also be used for law enforcement purposes.

ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act of 1974, these records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a (b) (3) as follows: Under DoD Blanket Routine Use #1. For law enforcement purposes to …federal, state, local, or foreign (law enforcement agencies), charged with enforcing or implementing the statute, rule, regulation, or order issued pursuant thereto. The DoD 'Blanket Routine Uses' set forth at the beginning of the OSD compilation of systems of records notices apply to this system.

DISCLOSURE REQUIREMENT – THIS INFORMATION IS VOLUNTARY: Voluntary. However, failure to provide the requested information may result in denial of a DBIDS card or visitor’s pass and denial of entry to DoD installations and/or facilities.

CONDITIONS APPLICABLE ON RECEIPT: I understand that the ASG-KU Installation Access (IA) Card is valid only through the expiration date indicated. Exceptions may require additional screening, interview and background checks. It should also be known that any derogatory information returned from the applicant's background investigation or failure to comply with screening/interview requirements may reflect adversely on consideration for access and may result in barment proceedings being initiated. Its intended use and authorizations are limited to those indicated on this form and the card. I understand that the ASG-KU IA Card is US Government property, that it is not transferable, that it is not to be altered in any way, and that it must be surrendered upon request of the US

Government, its designated representative, or the issuing agency. I understand that while on any ASG-KU Installation my person, possessions, vehicle and work area are subject to search at the discretion of the US Government or its designated representative. I understand that I am liable for the cost of replacement for my IA Card if lost. Any falsification on this form will result in immediate revocation of access privileges.

SECTION I - Demographics

1. Last Name (Surname) 12. Title/Position 13 Rank/Grade

14. Citizenship: If dual citizen list both 15. Race

3. Middle Name/Suffix: 16. Address (Building Name/Number, Street Name/Number, etc):

4. Passport Number:

2. First Name (Given Name)

SECTION II - Access Information

5. Foreign Identification Number: Expiration Date (dd/mmm/yy): 18. City, State, Zip code: 19. Country

6. Date of Birth (dd/mmm/yy): 7. Height (inches): 8. Weight (pounds):

Expiration Date (dd/mmm/yy): 17. Address Type:

20. Home Phone Number: 21. Mobile Phone Number:

To:To:

Organization AddressHome Address Company AddressOffice Address

Male Female

Escort Request

New

Upgrade of Privileges

Lost/Stolen IA Card

Enclosure 1 - ASG-KU DES FORM 190-16.01-Access Application (01 November 2022)

DBIDS #

of Applicant

Dates Requested FOR EAL ONLY:

FFrroomm::

25. 27.

Renewal

54. Remarks:

SECTION V - Installation Access (IA) Card Holder Acknowledgement

ASG-KU ACCESS APPLICATION

43. AA Last Name: 44. AA First and Middle Initial: 45. AA Rank/Grade or Equivalent:

SECTION IV - Appointed Authority (AA) Information and Recommendation

55. As a ASG-KU IA Card holder, I acknowledge the following:

1. All persons, their personal property, US Government property, and vehicles may be searched on entry, while within the confines of, or when leaving US Forces installations. Persons attempting to gain entry, who refuse to identify themselves, provide digitized fingerprint minutia data (DFMD), hand geometry scan, or consent to search, will be denied access.

2. If I am authorized escort privileges, I understand that I am agreeing to monitor that person’s actions at all times, and I accept full responsibility for that person’s conduct while on the installation.

3. IA Cards are US Government property. Any Military Police Officer, Law Enforcement, Security Force or Access Control personnel may confiscate an IA Card that has expired, is being used fraudulently, and is being presented by a person other than the person to whom it was issued, or is obviously altered, damaged, mutilated or photocopied.

4. I must surrender my pass when

a. It is replaced (except when lost or stolen).

b. I no longer require access.

c. My sponsor or status changes.

d. I resign, am terminated, or am no longer officially sponsored.

5. If I lose my IA Card or if it is stolen, I must immediately notify either the Law Enforcement Station or Installation Access Office. Failure to do so is grounds for denying a replacement card.

6. Violations of ASG-KU security policies may be grounds for denying access to US Forces Installations and lead to confiscation of all installation access documents.

I acknowledge by my signature that I have read and understand the policy, requirements, and responsibilities above.

56. (Print/Type) Last, First, Middle Initial: 57. Signature: 58. Date (dd/mmm/yy):

65. AREAS OF ACCESS:

62. AA Registration:

SECTION VII - Screening Team Use Only

66. Category Classification:

67. Name of Person Entering Data/Collecting Biometrics: 68. Signature/Date of Person Entering Data/Collecting Biometrics: 69. DBIDS Number of Person Entering Data/Collecting Biometrics:

SECTION VI -Access Office Use Only

59. Name and Rank/Title of Person Approving Application: 60. Signature and Date of Person Approving Application

63. ESCORT Privileges: 64. DRIVING Privileges:

51. AREAS OF ACCESS: Directorate/COR/AA must initial for each camp required.

(Note Access is based on the individual’s need as stated in their contract. It is strictly prohibited to access areas not specified in their contract.) Initial:

48. AA Mobile Number:

50. AA Signature and Date:

46. AA Unit Organization: 47. AA Work Number:

49. AA Email Address:

53. DRIVING Privileges:52. ESCORT Privileges:

61. EXPIRATION Date of IA Card (dd/mmm/yy)

71. Supporting Documents Enclosed (if applicable)

Buehring Yes No

OCN: YELLOW Stripe Host Nations Exception: BLUE StripeEmergency Services: RED StripeUS CITIZEN: GREEN Stripe

COR Validated

Yes No

Initial:

OCN w/ Enc 7

Yes NoYes No OCN w/ Enc 7

Initial:

Enclosure 1 - ASG-KU DES FORM 190-16.01-Access Application (1 November 2022)

APPROVED VERIFIED

70. Screening Result:

73. Date of LAST BATS:

71. Language:

72. Printed Name of Screener

SPODArifjan

Buehring SPODArifjan

74. SCREENING EXPIRATION DATE: