Attachment_9_-_Pass_Information_Sheet.pdf

FOR OFFICIAL USE ONLY

PASS INFORMATION SHEET

DATE:

EXPIRATION DATE:

NAME OF COMPANY:

START DATE:

VALID DAYS: M T W TH F S SUN VALID TIMES:

SPONSOR NAME: SPONSOR PHONE #:

NAME SSAN

DRIVER’S

LICENSE

Ensure individuals bring the following items to Pass and Registration; (1) Driver’s License, (2) Registration and (3) Proof of insurance

SPONSOR SIGNATURE DATE

Privacy Act Statement PRIVACY ACT-1974 as Amended applies – This memo may contain information which must be protected IAW DOD 5400-11, and it is For Official Use Only (FOUO) AUTHORITY: 10 U.S.C. 8013; 44 U.S.C. 3101; and EO 93397 PRINCIPAL PURPOSES: Used to record information and details of criminal activity which may require investigative action by commanders, supervisors, police, special agents, etc. ROUTINE USES: Information may be disclosed to Pass and Registration to determine base access. DISCLOSURE IS VOLUNTARY: SSN is used to positively identify the individual as a conduit to check past criminal activity records. Failure to provide the request information will affect your ability to gain access to March Air Reserve Base, CA.

STATE DOB

Attachment 9

FA466419BA008