Exhibit G - ASG-KU DES FORM 190-16.04 ENCLOSURE 11.pdf

E nclosure 11 - ASG-KU DES FORM 190-16.01-Host Nation Military Access Application (9 August 2022)

DBIDS #

of Applicant

ASG-KU HOST NATION 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

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 (معلومات شخصیة)

1. Last Name (لقب): 14. Ministry (وزارة)12 Rank/Grade (رتبة):

2. First Name (الاسم الاول): 15. Citizenship: If dual citizen list both (المواطنة): 16. Nationality (الجنسیة):

3. Middle Name/Suffix (الاسم الأوسط / اللاحقة): 17. Address (Building Name/Number, Street Name/Number, etc) (عنوان):

4. Passport Number (رقم جواز السفر): Expiration Date (تاریخ إنتھاء الصلاحیة) (dd/mmm/yy):

20. Address Type (نوع العنوان):

Home (إقامة) Office (مكتب) Other (آخر)

5. Kuwait Civil Identification Number (رقم التعریف المدني): Expiration Date (dd/mmm/yy):

18. City, State, Zip code (المدینة ،البلدیة ، الرمز البریدي): 19. Country (دولة):

6. Date of Birth (dd/mm/yy) ( :(تاریخ المیلاد 7. Height (الطول بالبوصة): 8. Weight (الوزن بالباوند): 21. Mobile Phone Number (رقم ھاتف الجوال): 21. Work Phone Number (رقم ھاتف العمل):

9. Gender (جنس):

Female امرأة

10. Eye Color (لون العین): 11. Hair Color (لون الشعر): 24. New Registration (التسجیل الأول): 25. Renewal (تجدید البطاقة):

SECTION III - Military Sponsor (OIC or NCOIC from Assigned Department) فقط للكتابة الأمریكیة

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

30. Department Director: 31. Department Director DSN Phone Number:

32. Military Sponsor Rank, Last Name, First Name, MI: 33. Military Sponsor Title and/or Position:

34. Military Sponsor DSN Phone Number: 35. Military Sponsor Mobile Number:

36. Military Sponsor Email: 37. Military Sponsor Signature and Date:

40. Areas of Access:

Arifjan Buehring SPOD

41. Escort Privileges:

Yes No INT:

42. Driving Privileges:

Yes No INT:

Male رجل

ASG-KU-DHNA-20220809-01

13. Title/Position (اللقب / الوظیفة):

E nclosure 11 - ASG-KU DES FORM 190-16.01-Host Nation Military Access Application (9 August 2022)

ASG-KU ACCESS APPLICATION

SECTION IV - Installation Access (IA) Card Holder Acknowledgement

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.

43. (Print/Type) Last, First, Middle Initial: (الاسم الكامل) 44. Signature (التوقیع): 45. Date (dd/mmm/yy) (تاریخ):

SECTION V - Access Office Use Only * فقط للكتابة الأمریكیة *

46. Name and Rank/Title of Person Approving Application: 47. Signature and Date of Person Approving Application 48. EXPIRATION Date of IA Card (dd/mmm/yy)

49. Approved Memorandum:

Yes No

50. ESCORT Privileges:

Yes No

51. DRIVING Privileges:

Yes No

52. AREAS OF ACCESS:

Arifjan Buehring SPOD

53. Category Classification:

OCN: YELLOW Stripe Host Nations Exception: BLUE Stripe Emergency Services: RED Stripe

54. Name of Person Entering Data/Collecting Biometrics: 55. Signature/Date of Person Entering Data/Collecting Biometrics: 56. DBIDS Number of Person Entering Data/Collecting Biometrics:

ASG-KU-DHNA-20220809-01