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B-180, 20220331, V3 PREVIOUS EDITIONS ARE OBSOLETE PAGE 1 OF 2

LONG TERM PASSES FOR CONTRACTORS/VENDORS/EMPLOYEES

END DATE

PRIVACY ACT STATEMENT

AUTHORITY: Section 3101, Title 44, US Code, 5 USC 552A PRINCIPAL PURPOSES: The purpose of requesting personal information is to assist security personnel in developing records to document contractor employee suitability for access to Bellows Air Force Station, Hawaii to work under Air Force or local contracts. The social security number and date and place of birth are necessary to identify persons, maintaining records, and for criminal history/background checks.

ROUTINE USES: This information may be used to determine suitability of persons desiring access to Bellows Air Force Station as well as for other lawful purposes including law enforcement and litigation.

DISCLOSURE IS VOLUNTARY: Disclosure of requested information is voluntary. However, failure to provide information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the contract while serving in the capacity of prime contractor or subcontractor/supplier/employee.

I. INSTRUCTIONS

1. All information must be typed; Last Name, First Name, MI, DOB, Gender, Citizenship, Driver’s License # or SSN/Passport # (if applicable)

2. Visitors must have valid vehicle registration, safety inspection, insurance, and driver’s license or other form of picture ID (Naturalization

Certificate/Permanent Resident Card if applicable).

3. This form must be submitted 5 duty days prior to gaining access. Applications will be discarded after 30 days and a new form must be submitted.

4. Days and hours working/visiting must be specific.

5. Visitor Pass expiration date must be entered.

6. Incomplete forms or forms with errors will be returned for correction and will not be processed.

II. SPONSORS INFORMATION

NAME (Last, First Middle Initial) RANK TELEPHONE

HOME DUTY

UNIT EMAIL

III. REQUESTERS INFORMATION (Point of Contact for the Company/Agency Requesting Access) NAME (Last, First Middle Initial) RANK TELEPHONE

HOME DUTY

UNIT EMAIL

IV. EMPLOYEE/VISITOR INFORMATION

COMPANY/AGENCY/GROUP NAME START DATE END DATE

LOCATION OF WORK BASE ACESS

DAYS (ex. SUN - SAT) HOURS (ex. 0900-1630)

JUSTIFCATION (Brief description of work)

EMPLOYEE/VISITOR LIST

LAST NAME FIRST NAME MI DOB GENDER CITIZENSHIP

DRIVER’S LIC.

#/STATE ID #

(INCLUDE STATE)

SSN OR

PASSPORT #

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EMPLOYEE/VISITOR LIST (CONTINUED)

LAST NAME FIRST NAME MI DOB GENDER CITIZENSHIP

DRIVER’S LIC.

#/STATE ID #

(INCLUDE STATE)

SSN OR

PASSPORT #

THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A FALSE, FICTICIOUS OR FRAUDULENT CERTIFICATION MAY RENDER THE

MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED STATES CODE, SECTION 1001.

V. SIGNATURES

REQUESTER'S

SIGNATURE

(If applicable)

Date

SPONSOR’S

SIGNATURE Date

VI. SECURITY FORCES

NCIC AFJIS DBIDS

COMMENTS (List any derogatory information)

BDOC

SIGNATURE: Date

NCOIC

SIGNATURE: Date