Attachment_6_USAFCENTCOM_Installation_Access.xlsx

USAFCENT INSTALLATION ACCESS APPLICATION

DATA REQUIRED BY THE PRIVACY ACT OF 1974

(Sections 3013,5013, and 8013. Title 10, United States Code, Executive Order 9397, and U.S.C. Section 552a)

Section 1- Access Information

Last, First Middle

Nationality Aliases:

Country of Birth Province / State of Birth City /District of Birth

Telephone (Home): Cell Phone: Work Phone:

Military Branch: Employer Phone Number:

Employer Street Addrs: Employer Neighborhood:

Employer State/Provinc Employer Country:

Employer City Contract Expiration Date:

Project Name: Supervisor's Phone:

Supervisor's Name Last, First, MI:

USAFCENT Installation Access Application (IAA) Feb -2009 Page 1 of 4

AUTHORITY: DOD 5200.08R, AFI 31-101, CENTCOM OPORD 05-02, USAFCENTI 31-105 and Individual USAFCENT Installation Access Policies

PRINCIPAL PURPOSE: To establish positive identification of all personnel requiring access to USAFCENT Installations, including Host Nation Military and Civilian employees, Foreign National employees, and contractors supporting the U.S. Military mission at USAFCENT Installations. Also included are non-affiliated agencies and groups granted special installation access by the U.S. Government.

MANDATORY DISCLOSURE REQUIREMENT: Failure to provide the below requested information, including social security number, passport number, Host Nation Government Identification number, and/or Nation of Origin Identification Number, will result in the disapproval of this application. Disapproved applicants will be denied issue of an DBIDS Access Card (DAC) and access to USAFCENT controlled facilities. Personal information such as SSAN, Passport or Governmental Civil Identification provides an individual with a unique identification and will be handled as OFFICIAL USE ONLY in accordance with U.S. Federal Statutes.

CONDITIONS APPLICABLE ON RECEIPT: By virtue of signing this application and upon receipt of a DAC you understand the USAFCENT DAC is valid only through the expiration date indicated. Its intended use and authorizations are limited to those restrictions indicated on this form and the DAC. I understand that the USAFCENT DAC is a the property of the U.S Government, it is non-transferable, and if it is altered in any way access will be denied. It must be surrendered upon request of the U.S Government, its designated representative or the issuing agency. I understand that while on any USAFCENT Installation, my person, possessions, vehicle and work area are subject to search at the discretion of the U.S Government or its designated representative. I understand that I am liable for the cost of replacement for my DAC if lost.

USAFCENT INSTALLATION ACCESS APPLICATION

Section 5 Sponsor Information

Sponsor's Phone #: Sponsor's Email Address:

Sponsor's Signature:

R/A Phone # : R/A Email Address:

R/A Signature: Date:

Requesting Category Code: (Card Color) Category I (Red) Category II (Blue) Category III (White) Category IV(White) Category V (Blue) Escorted Unescorted Unescorted Unescorted Unescorted

Escorted Unescorted Unescorted Unescorted Unescorted

Facility Access: DFAC Fitness Ctr Phones Cell Phone Medical Billeting MWR PX/BX

Approving Authority Signature: Date:

(If applicable)

Access Card Status: Issue Location: Issue Date:

Card Replacement Reason: Damaged Stolen Lost Unrecovered Other Explain Other:

Card Replacement Number: (If Applicable) Issued by Last, First, MI

IDENT Yes No Derogatory IDENT Yes No BFC Transaction Ctrl Num (TCN)

Derogatory Information/Remarks:

Applicant's Last Name:

USAFCENT Installation Access Application (IAA) Feb - 2009 Page 2 of 4

USAFCENT INSTALLATION ACCESS APPLICATION

I hereby authorize the release of information requested by USAFCENT for the purpose of determining my suitability for access to USAFCENT installations:

___________(initials)

Acknowledgement of USAFCENT DBIDS Access Card Holder Responsibilities

Upon signing this form and accepting a USAFCENT DBIDS Access Card (DAC), I acknowledge the following:

1. All persons, their personal property, U.S. Government property, Commercial Business Property, and vehicles may be searched upon entry, while within the confines of, and/or when leaving the U.S. Forces Installations. Persons attempting to gain entry, who refuse to identify themselves, provide biometric verification data, or consent to be searched will be denied access or removed from the Installation.

2. If I am authorized escort privileges, I understand I am agreeing to monitor those persons, I am charged with escorting, monitoring thier actions at all times and I accept FULL responsibility for those individual(s)' conduct while they are on the Installation.

3. DACs are U.S. Government property. Any Military Police Officer, Law Enforcement, Security Forces Member, or Access Control person may confiscate a DAC that has expired, is being used fraudulently, is being used in any way other than intended, is being used by any person other than to whom it was issued, or if it has been altered, damaged, mutilated or photocopied.

4. I MUST surrender my DAC when:

4.1 It is replaced (except when lost or stolen)

4.2 I no longer require access

4.3 My sponsor or status changes

4.4 I resign, am terminated, or no longer officially sponsored

5. If I lose my DAC or it is stolen, I must immediately notify either Security Forces personnel or the DBIDS Installation Access Registration Office. Failure to do so may be grounds for denying a replacement card.

6. Violations of USAFCENT security policies, procedures, or instructions may be grounds for denying access to U.S Forces Installations and may lead to the revocation and confiscation of the DAC.

7. I acknowledge by my signature I have read and understand the policies, requirements and responsibilities listed above.

(Print Name) Last, First, MI Signature Date

Signature: Date:

Signature: Date:

Copy of Civil ID (Front and Back) Entry Visa with Entry Stamp Original Sponsor Letters (English and Arabic) Contractor Support Letters (English and Arabic) Copy of LOI, LOA, or Orders Copy of Driver's License Copy of National ID Signature Card Verification Other

Applicant's Last Name:

USAFCENT Installation Access Application (IAA) Feb- 2009 Page 3 of 4

USAFCENT INSTALLATION ACCESS APPLICATION

Section 11 Vehicle Information

Vehicle Identification Number:

Color: Manufacture:

Model: Year: Body Type:

Registration Plate Number: Reg Plate Type:

Section 12 Vehicle Driver Information

1 Driver Name (Last, First MI) ID #

2 Driver Name (Last, First MI) ID #

3 Driver Name (Last, First MI) ID #

4 Driver Name (Last, First MI) ID #

5 Driver Name (Last, First MI) ID #

Approving Authority Signature: Date: Back to Page 2

Signature: Date:

Signature: Date:

SSM/ Interviewer Notes:

USAFCENT Installation Access Application (IAA) Feb- 2009 Page 4 of 4