Attachment_4_-_SFG_Pass_Request_Form.pdf

FOR OFFICIAL USE ONLY

KIRTLAND AFB

PASS REQUEST

SPONSOR'S INFORMATION

FIRST NAME

MIDDLE NAME

LAST NAME

SSN or DOD ID Number

DATE OF BIRTH

SEX M F (circle one)

ORGANIZATION

ORGANIZATION ADDRESS

DUTY PHONE

CONTRACTOR'S//////VISITOR'S INFORMATION

FIRST NAME

MIDDLE NAME

LAST NAME

DATE OF BIRTH

SEX M F (circle one)

SSN (MANDATORY)

HOME ADDRESS

PHONE # (Where you can be contacted/daytime)

Contractor/Visitor’s Personal Identification (State or Government Issued)

ID Type (For example: Drivers License)

ID NUMBER

STATE OF ISSUANCE

Contractor’s Company Information

COMPANY NAME/PHONE

COMPANY ADDRESS

Contractor/Visitor’s Citizenship

US CITIZEN? YES ____

NO ____ (IF NO, STATE COUNTRY OF CITIZENSHIP) _______________

Additional Pass Information

DESTINATION on Kirtland AFB

DURATION OF PASS *****(Date of Expiration) (Not to exceed 1 yr) Month: Day: Year:

DAYS REQUIRED ACCESS/TIME

**NOTE: Circle the days access is required and indicate the access time requested for example (0700-1900). M TU W TH F SAT SUN ACCESS TIMES ( )

PRIVACY ACT STATEMENT

PRIVACY ACT STATEMENT: AUTHORITY: Title 5 USC Section 301, Departmental Regulation Principle Purpose:

To implement AFI 31-201, Installation Security and 31-204, Air Force Motor Vehicle Traffic Supervision ROUTINE PURPOSE: To request and record the issuance of a Visitor when the use of another form is not authorized or specified.

Failure to provide any of the information requested may result in non-issuance of the Visitor Pass. Disclosure of the SSN is voluntary acceptance of these terms constitutes approval for a criminal history background check to be conducted as part of the request approval process. This information is necessary for validation of identity and determination of entry eligibility onto Kirtland Air Force Base. Failure to provide this information may result in a non-issuance determination by the issuing authority.

FOR OFFICIAL USE ONLY

FOR S5B USE

Received: ___________ Contacted: ___________ Processed: ___________