02. JBAB 5512 fillable.pdf

JOINT BASE ANACOSTIA-BOLLING LOCAL POPULATION ID/BASE ACCESS PASS REGISTRATION FORM

PLEASE COMPLETE BOTH SIDES OF FORM

ROUTINE USE(S): To designated contractors, Federal agencies, and foreign officials for the purpose of granting access to this DOD/USAF installation.

FOR CONTRACTORS/SERVICE/VENDER PROVIDERS: EMPLOYMENT ACTIVITY INFORMATION

NO

1. LAST NAME:

PRIOR FELONY CONVICTIONS

REQUIREMENT TO RETURN LOCAL POPULATION ID CARD

5. GENDER (CIRCLE ONE)

MALE/FEMALE

36. HAVE YOU EVER BEEN CONVICTED OF A FELONY?

INITIAL:

20. DATE ISSUED -

24. DATE ISSUED

32. COMPANY NAME AND ADDRESS (INCLUDE CITY/STATE/ZIP CODE):

31. DATE EXPIRES30. DATE ISSUED

12. WEIGHT (POUNDS): 13. HEIGHT (INCHES): 14. HAIR COLOR:

16. HOME ADDRESS (INCLUDE CITY, STATE, ZIP CODE):

33. COMPANY PHONE NUMBER -

2. FIRST NAME: 4. SUFFIX:

6. SOCIAL SECURITY NUMBER

10. U.S. CITIZEN (CIRCLE ONE): YES/NO

3. MIDDLE NAME:

7. DATE OF BIRTH: 8. CITY/STATE OF

BIRTH:

9. COUNTRY OF BIRTH:

11. CITIZENSHIP, IF NOT U.S. (COUNTRY):

22.PASSPORT NUMBER

29. OTHER APPROVED IDENTIFICATION

17. CELL/HOME PHONE:

15. EYE COLOR:

26. GREEN CARD NUMBER 27. DATE ISSUED

DISCLOSURE: Providing registration information is voluntary. Failure to provide requested information may result in denial of access to this installation.

PRIVACY ACT STATEMENT: This information is protected under the Privacy Act of 1974. This form will be considered confidential when filled out.

AUTHORITY: 10 U.S.C., Department of Defense Manual (DoDM) 5200.08 Volume 3, AFMAN 31-101_Volume 3 I.A.C. & AFI 31-101 Integrated Defense

PURPOSE(S): To control physical access to Department of Defense facilities over which the 11th Security Forces Squadron has law enforcement jurisdiction.

35. SUPERVISOR PHONE #: 34. SUPERVISOR NAME AND ADDRESS (INCLUDE CITY/STATE/ZIP CODE):

21. DATE EXPIRES -

25. DATE EXPIRES

18. STATE ID/DRIVER'S LICENSE: 19. STATE ISSUED -

APPLICANT INFORMATION

IDENTIFICATION DOCUMENTS

23. COUNTRY ISSUED

28. DATE EXPIRES

37. I UNDERSTAND THAT I AM REQUIRED TO RETURN MY LOCAL POPULATION IDENTIFICATION CARD TO THE

JOINT VISITOR CONTROL CENTERWHEN IT EXPIRES OR IF MY EMPLOYMENT IS TERMINATED FOR ANY REASON.

INITIAL:

JBAB 5512 BASE ACCESS REGISTRATION FORM APR-2021 1

YES

AUTHORIZATION/RELEASE:

FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD RESULT IN FINES AND/OR IMPRISONMENT UP TO 5 YRS.

BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE YOU COMPLETED ALL QUESTIONS CORRECTLY.

I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE BY ME ON THIS FORM ARE

TRUE, COMPLETE AND CORRECT.

___________DATE: 21 __________________________SIGNATURE:

PAPER CARD

CRIMINAL HISTORY BACKGROUND CHECK IS REQUIRED FOR BASE ACCESS

RELEASE (CONT.) AND CERTIFICATION

46. BACKGROUND (OpenFox) PERFORMED BY:

52. DBIDS OPERATOR

48.VETTED DATE

TIMES AND DATES OF VISIT

EXPIRATION DATES

44. REGISTRATION EXPIRATION

DATE

38. I hereby authorize the USAF/DOD and other authorized Federal agencies to obtain any information required from the Federal government and/or state agencies, including but not limited to , the Federal Bureau of Investigation (FBI), the Defense Security Service (DSS), & the U.S. Department of

Homeland Security (DHS). I have been notified of USAF right to perform minimal vetting and fitness determination as a condition of access to

DOD/USAF installations. I understand that I may request a record identifier; the source of the record and that I may obtain records from the state Law

Enforcement Office as may be available to me under the law. I also understand that this information will be confidential.

39. I release any individual, including records custodians, any component of the U.S. Government or the individual State Criminal History Repository supplying information, from all liability for damages that may result on account of compliance, or any attempts to to comply with this authorization.

This release is binding, now and in the future, on my heirs, assigns, associates, and personal comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representatives of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

40.GOVERNMENT SPONSOR NAME AND AGENCY: 41. SPONSOR/ DoDI NUMBER 42. GOVERNMENT SPONSOR PHONE

NUMBER

FOR OFFICIAL USE ONLY

I have been advised of the required crimal history background check and given my consent by providing my sigature in this block.

COMPLETED BY JOINT VISITOR CENTER PERSONNEL

43. INFORMATION VERIFIED BY: 45. VEHICLE INSURANCE

EXPIRATION DATE

50. DURATION 51. COMPANY NAME- SUB OF AGENCY-

49.VETTED EXPIRATION DATE

47. RESULTS OF BACKGROUND CHECK:

JBAB 5512 BASE ACCESS REGISTRATION FORM APR-2021 2