Attachment_4_DARB_4.pdf

Attachment 4

DARB 4 - DOBBINS SECURITY FORCES PRE-AUTHORIZATION

GROUP/SPECIAL EVENT ACCESS REQUEST FORM

Authenticated by Name, Rank/Grade:_________________________________ Date:_______________ Time:_______________ Pages_____ of _______ Signature:_______________________________________ Distribution: Police Services, Pass & ID, Gate 1, Gate 2, BDOC, Privacy Act - 1974 as Amended Applies--This communication may contain information which must be protected IAW DoD 5400.11R, AFI 33-119, AFI 3-129 and is "FOR OFFICIAL USE ONLY (FOUO)"

1. Sponsor Register in DBIDS: YES NO Note: All DoD ID Cardholders must be registered in DBIDS to sponsor a group of visitors/guest on Dobbins.

2.Effective Time of Visit: 1000 Effective Date/s of Visit: 7 May 2015

3. Sponsor/Escort Full Name:

Kenneth Jacob

4. Expiration Time of Visit: 1400 Expiration Date of Visit: 7 May 2015

5. Reason for Access:

Attend Site Visit for Rubber Removal Solicitation

6. Sponsor/Escort Contact Number Work:655-5745 Cell:

7. Location (building/s or area to be occupied) at Dobbins Bldg 812

8. Special Notes Contractor personnel require access to Dobbins ARB to attend site visit for Rubber Removal/Maintain Markings solicitation FA6703-15-R-0002.

9. The individuals listed below are a visitor/guest of: . I take full responsibility for the individuals and to the extent of my knowledge, these guest/visitors are trustworthy and reliable and does not possess any adverse character traits or exhibit any indications of aberrant behavior that would constitute an unreasonable risk to the health and safety of members assigned and working on DARB. I, therefore request that when these individuals satisfactorily complete their required criminal history background check, that these visitors/guest be granted clearance for unescorted access to the installation. I have briefed the listed individuals of the entry procedures required to enter Dobbins Air Reserve Base. My guests understand that upon entering the facility they may be required to submit to an installation entry point check. The driver must have a valid driver's license, proof of vehicle auto insurance, proof of vehicle registration and must abide by all base traffic instructions. Passengers must have valid photo identification. The use of seatbelts is mandatory on Dobbins ARB.

10. SIGNATURE: ________________________________ 11. DATE:

12. DRIVER’S LICENSE NUMBER:

13. STATE ISSUED:

14. SPONSOR’S DATE OF BIRTH (MUST PROVIDE):

15. SPONSOR’S SOCIAL SECURITY NUMBER (MUST PROVIDE):

Please note: The Sponsor is required to complete the form and must either fax to: 678 655-5999 or hand deliver to Pass & Registration Office, Bldg 866. Email submissions cannot and will not be accepted because of Information Assurance policy. Also, if the Sponsor is not registered in DBIDS at the time of submission, the request for access will not be accepted.

1054949371C Typewritten Text

Attachment 4

DARB 4 - DOBBINS SECURITY FORCES PRE-AUTHORIZATION

GROUP/SPECIAL EVENT ACCESS REQUEST FORM

Authenticated by Name, Rank/Grade:_________________________________ Date:_______________ Time:_______________ Pages_____ of _______ Signature:_______________________________________ Distribution: Police Services, Pass & ID, Gate 1, Gate 2, BDOC, Privacy Act - 1974 as Amended Applies--This communication may contain information which must be protected IAW DoD 5400.11R, AFI 33-119, AFI 3-129 and is "FOR OFFICIAL USE ONLY (FOUO)"

16.Type Visitor:

(Please check one) Personal Visitor Business Visitor Vendor/Service Worker

17.Date of Request:

18. Sponsor Organization:

19. Sponsor Name:

20. Time and Date/s of visit:

21. Title of Event 22. Sponsor Contact Number ( Cell phone # preferred ):

23. Last Name, First, MI 24. Citizenship 25. Date of Birth 26. Make/Model of vehicle

27. Vehicle Plate/State (tag)

1.EXAMPLE: SMITH, JOHN D. U.S 12/25/1960 BMW 535 ABC 2900/ GA

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1054949371C Typewritten Text

1054949371C Typewritten Text