ATTACH__5_-_DARB_3.pdf

DARB 3 - DOBBINS SECURITY FORCES PRE-AUTHORIZATION INDIVIDUAL VISITOR ACCESS

REQUEST FORM

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 will not be accepted because of Information Assurance policy. If the Sponsor is not registered in DBIDS at the time of submission, the request for access will not be accepted.

PRIVACY ACT INFORMATION (FOR SF USE ONLY: GCIC/NCIC CHECK) YES NO

INFORMATION SHEET TO REQUEST AN ACCESS PASS

(SPONSOR INFORMATION) REGISTERED IN DBIDS YES NO

1. FIRST NAME: 8. DATE(S) OF VISITS: FROM: TO:

2. MIDDLE NAME: 9. TIME OF VISIT: FROM: TO:

3. LAST NAME: 10. E-MAIL (WORK ONLY):

4. UNIT ORGANIZATION: 11. BLDG #:

5. PHONE # (WORK): 12. CELL PHONE # (PREFERRED):

6. SSN (LAST 4): 13. DATE OF BIRTH (MUST PROVIDE):

7. HOME or ORGANIZATION ADDRESS 14. REASON FOR ACCESS:

(VISITOR/GUEST INFORMATION)

15. FIRST NAME: 21. DATE OF BIRTH (MUST PROVIDE):

16. MIDDLE NAME: 22. SSN (MUST PROVIDE FOR SERVICE

WORKERS/CONTRACTORS):

17. LAST NAME: 23. PHONE #:

18. ORGANIZATION: 24. LOCATION OF VISIT:

19. TYPE OF VISITOR Personal Business Contractor/Service Worker/Vendor

20. U.S CITIZEN YES NO (IF NO, PLEASE LIST COUNTRY

PRIVACY ACT STATEMENT: AUTHORITY: Title 5 USC, Section 301, Departmental Regulation PRINCIPAL PURPOSE: To implement AFI 31-101, Installation Security and 31-204, Air Force Motor Vehicle Traffic Supervision ROUTINE PURPOSE: To request and record the issuance of a Visitor/Vehicle Pass when the use of another form is not authorized or specified. Failure to provide any of the information requested may result in non-issuance of the Visitor/Vehicle Pass. Disclosure of date of birth and SSN is voluntary.

However, this information is necessary for validation of identity and may result in a non-issuance determination by the issuing authority.

The individual listed above is a visitor/guest of: . I take full responsibility for the individual and to the extent of my knowledge, this guest/visitors is 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 Dobbins Air Reserve Base. I, therefore request that when this individual satisfactorily complete their required criminal history check, that this visitors/guest be granted clearance for unescorted access to the installation. I have briefed the above individual of the entry procedures required to enter Dobbins Air Reserve Base. My guest/visitor understands that upon entering the installation 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, and proof of vehicle registration and they must abide by all base traffic instructions. Passengers must have valid photo identification. The use of seatbelts is mandatory on Dobbins ARB.

21. SIGNATURE: 22. DATE:

Version 20130614

Attachment #5 FA670318B0005