FA486110RA200_NELLIS_MACC_Atch19 NAFB 0-74 Range Pass.pdf

99TH RANGE GROUP FACILITIES VISIT REQUEST/AUTHORIZATION

This form is subject to the Privacy Act of 1974 (see reverse)

FROM: (Name and Phone Number) Organization:

TO: 99th Range Squadron 3770 Duffer Dr Nellis AFB NV 89191-7001

Commercial Phone: (702) 652-3606

DSN 682-3606 FAX 682-3808

Name of Your Range Squadron Point of Contact

Tolicha Peak/Tonopah Ranges Only

NAME (LAST, First, M.I.) RANK Job Title SSAN Clearance Organization Citizenship DOB Place of Birth

NAFB Form 0-74 Feb 96 (Electronically Generated)

Mode of Transportation: Entry/Exit Location Date of Visit

FROM: TO:

Areas to be Visited: Check all that apply Tonopah Area 10 Communications Sites:

Tonopah EC East

Range Control Center: Ranges: 71N 74C Tonopah EC West

Building 200 61 64N 71S 75W Tonopah Cactus EC Other:

Red Forces 62 64S 74A 75E Tolicha Peak ECR

Blackjack 63 66S 74B 76 Tolicha Peak EC South

Purpose of Visit in Detail:

Naturalization Information: Required for all naturalized citizens needing access to Tolicha Peak/Tonopah Ranges

Naturalization Number: Place of Naturalization and Date:

Typed Name, Grade and Title of Requesting Official: Duty Phone:

Date:

Coordination: 99 RANS Security Manger Department of Energy

99 RANS/Det 1 Other

99 RANS/Det 2 (All Tonopah and Tolicha Peak Coordination) Other

Bldg 200 Security Other

99 RANS/CC/DO Other

APPROVED FOR ACCESS APPROVED FOR ACCESS WITH ESCORT LISTED BELOW DISAPPROVED

Typed Name, Grade, and Title of Approval Authority: Signature:

Date Submitted: Suspense Date:

Remarks:

PRIVACY ACT STATEMENT

AUTHORITY: 10 USC 8013

PRINCIPAL PURPOSE: For positive identification for entry into United States Air Force restricted and ROUTINE USES: None DISCLOSURE IS VOLUNTARY: Furnishing this information is voluntary. If you do not give the required information, you will not be allowed entry into these areas.

NAFB Form 0-74 Feb 96 (Back) (Electronically Generated)