Atch_42_APPENDIX_21_NAFB_Form_0-74 _Range_Pass.pdf

NEVADA TEST AND TRAINING RANGE VISIT REQUEST/AUTHORIZATION

This form is subject to the Privacy Act of 1974

All badges must be picked up at Nellis AFB, Building 200.

I. SEND TO:

NTTR Security Voice: 702-653-4606 DSN 348-4606 3770 Duffer Drive, Ste. 127 Fax: 702-653-4808 DSN 348-4808 Nellis AFB NV 89191 Email:NTTRSecurity@nellis.af.mil

FROM (Your Name and Phone Number) NTTR Sponsor / NTTR Host / NTTR Project Officer (This block is mandatory, if unknown call 702-653-4606)

Date of visit (DD-MMM-YY) (May not exceed 365 days) Name: FROM: TO:

Phone: (Requests must be forwarded to the NTTR security office, a minimum of 5 working days prior to start of visit.)

AREAS TO BE VISITED:

(Check all that apply)

BUILDING 200

(NTTR, Nellis AFB)

*SOUTHERN RANGES

(Ranges 61, 62, 63, 64, and 65)

CREECH AFB FLIGHT LINE

(This Will Not Allow Access to Creech

AFB)

*TOLICHA PEAK

(Ranges 75 and 76)

*TONOPAH TEST RANGE

(Area 10, EC East, EC West, R71 & R74)

**NORTHERN RANGES (US CITIZENS AND APPROVIED ALLIES ONLY)

PURPOSE OF VISIT IN DETAIL

TYPED NAME AND GRADE OF SECURITY OFFICIAL VERIFYING SECURITY CLEARANCE:

SIGNATURE DUTY PHONE:

DATE:

II. Visitor(s) Name(s): LAST, First, M.I.

(Continue on second page if needed)

Rank

(ENL, OFF, CIV)

Full SSN or Military ID Number Organization Clearance

(TS, S, None, Q, L) Current Country of Citizenship

DOB

(DD-MMM-YY) Country or State of Birth**

**NATURALIZATION NUMBER / DATE / PLACE: (Only required for naturalized citizens needing access to Tolicha Peak / Tonopah Ranges, attach additional pages if needed.)

1.

IF BORN TO U.S. PARENTS WHILE OVERSEAS

U.S. military parents stationed overseas

U.S. civilian parents living overseas

2.

*EOD SAFETY BRIEF IS REQUIRED PRIOR TO ENTERING ANY NUMBERED RANGE / SECURITY BRIEF REQUIRED PRIOR TO ACCESSING THE SOUTHERN RANGES TTR AND TOLICHA PEAK **A Naturalization number is required for naturalized citizens needing access to Tolicha Peak / Tonopah Ranges –If born to U.S. parents while overseas please state so in space provided above.

III. NTTR OFFICE USE ONLY

NTTR APPROVAL AUTHORITY: SIGNATURE: DATE: BADGED:____________________________

FILED / FAXED / SENT: ________________

DATABASED / DND: ___________________

PRIVACY ACT STATEMENT

AUTHORITY: 10 USC 8013

PRINCIPAL PURPOSE: For positive identification for entry into United States Air Force restricted and controlled areas.

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. This form requires the collection and maintenance of information protected by the Privacy Act (PA) of 1974. The authority to collect and or maintain the records prescribed in this instruction is 37 USC 301a. Privacy Act system notice F036 AF PC C, Military Personnel Records System, applies.

NAFB Form O-74 JUNE 21, 2011 (Electronically Generated) Page 1 of 3 mailto:98RANWSecurity@nellis.af.mil�

Visitor(s) Name(s): LAST, First, M.I.

(Continue on second page if needed)

Rank

(ENL, OFF, CIV)

Full SSN or Military ID Number Organization Clearance

(TS, S, None, Q, L) Current Country of Citizenship

DOB

(DD-MMM-YY)

Country or State of

Birth**

**A Naturalization number is required for naturalized citizens needing access to Tolicha Peak / Tonopah Ranges –If born to U.S. parents while overseas please state so in space provided above.

NAFB Form O-74 JUNE 21, 2011 (Electronically Generated) Page 2 of 3

Visitor(s) Name(s): LAST, First, M.I.

(Continue on second page if needed)

Rank

(ENL, OFF, CIV)

Full SSN or Military ID Number Organization Clearance

(TS, S, None, Q, L) Current Country of Citizenship

DOB

(DD-MMM-YY)

Country or State of

Birth**

**A Naturalization number is required for naturalized citizens needing access to Tolicha Peak / Tonopah Ranges –If born to U.S. parents while overseas please state so in space provided above.

NAFB Form O-74 JUNE 21, 2011 (Electronically Generated) Page 3 of 3