Attachment_12_-_SFS_FORM_30.pdf

MEMORANDUM FOR 366 SFS/S5B

FROM: 366 CONS/LGCB

SUBJECT: Request for Installation Entry Pass (366 SFS Form 30)

1. The following individual is requesting issuance of a Base Access Pass for the reason/time period listed. This letter is submitted IAW the 366 FW/Installation Defense Instruction.

TYPE/FILL OUT LEGIBLY OR APPLICATION WILL NOT BE PROCESSED

APPLICATION MUST BE FILED TWO WEEKS IN ADVANCE OF NEEDING BASE ACCESS

1. FULL NAME (FIRST, FULL MIDDLE NAME, LAST)

2. GENDER

M F

3. SSAN

4. DATE OF BIRTH (YYYY/MM/DD)

5. DRIVERS LICENSE NUMBER

6. STATE

7. CONTRACT DATES

8. CONTRACT #

FA4897-16-R-0005

9. DUTY HOURS & DAYS

10. EMPLOYED BY & SPONSOR

11. SPONSOR’S PHONE #

2. Does the contractor require access to classified material: NO

3. Individual listed has been informed a background and local files check will be conducted. The individual has been informed that disclosure of the above information is voluntary; however, failure to do so could result in the individual being denied access to the installation.

SHAUN J. CECIL

366 CONS/LGCB x-2665

1st Ind, 366 SFS/S5B

MEMORANDUM FOR:

Approved/Disapproved Authenticated on __________________ by (Date)

(Signature)

(Printed name & grade) 366 SFS/S5B

PRIVACY ACT STATEMENT: Authority: 50 U.S.C 797 and DOD Directive 5400.11.

PRINCIPAL PURPOSES: To identify personnel requesting unescorted entry on to MHAFB who are Official Business Guests/ Students/Visitors/Houseguests/Designated Agents/MHSD Employees/FW-CC Sponsored Guests. ROUTINE USES: Information will be used to conduct a wants and warrants, criminal history check through the Air Force Law Enforcement Terminal System (AFLETS) and the local files check at the security police reports and analysis section (366 SPS/S5R).

DISCLOSURE IS VOLUNTARY: Failure to provide the information could result in the individual being denied base access. This letter of request will be sent to 366 SFS/S5B two weeks prior to the date the individual concerned requires the pass. 366 SFS FORM 12, Jul 2010

DISPOSITION: This document is for official use only once completed; if this document is no longer in use shred it for protection of the contents.

FOR OFFICIAL USE ONLY

MEMORANDUM FOR 366 SFS/S5B