Attachment_12._AF_Form_2586.pdf

PREVIOUS EDITIONS ARE OBSOLETE.AF IMT 2586, 19981001, V2

UNESCORTED ENTRY AUTHORIZATION CERTIFICATE

PRIVACY ACT STATEMENT

I. IDENTIFICATION

II. CERTIFICATION OF REQUESTING OFFICIAL

III. DUTY

IV. RESTRICTED/CONTROLLED AREA COORDINATION

NAME

ORGANIZATION OR FIRM

GRADE Control Number(Last, First, Middle Initial)

AUTHORITY:

PRINCIPAL PURPOSE(S):

ROUTINE USE(S):

10 U.S.C. 8013, 44 U.S.C. 3101, and EO 9397.

To record personal information on an individual whose duty performance requires entry into Air Force restricted and controlled areas in order to coordinate with the appropriate official and determine when and what type of entry credential to use.

Control Number is used for individual identification. (Must be from government-issued ID such as CAC, driver license, passport, etc.)

None.

DISCLOSURE: Disclosure is voluntary however, failure to disclose information and SSN would result in not being allowed entry into these areas.

I certify that the individual whose name appears above has been the subject of a favorable investigation which meets the requirements of AFIs 31-101, 31-209 and 31-501, when applicable, for unescorted entry into restricted or controlled areas. I further certify, in the event the above named individual is a non-US national, that no US nationals can be made available to fill this position during the period indicated above, and that the granting of unescorted entry represents an exceptional requirement essential to the proper execution of the Command's mission. Such unescorted entry will not infringe upon the prohibited duties outlined in AFPD 31 -series directives, and is clearly consistent with the interest of national security.

78TH CIVIL ENGINEER GROUP

CONTRACTOR

COLOR HAIRCOLOR EYESWEIGHTHEIGHT

CITIZENSHIP (Check One)

(Typed)

(Describe duties that require unescorted entry into the areas indicated)

US CITIZEN ALIEN IMMIGRANT NON-US NATIONAL

NAME, GRADE AND TITLE

DUTY TITLE:

INITIAL SECURITY/OPSEC TRAINING DATE:

COMPANY NAME:

CONTRACT NUMBER:

PERFORMANCE START DATE:

PERFORMANCE END DATE:

PROGRAM MANAGER:

PM OFFICE SYMBOL:

PM DUTY PHONE:

PM BUILDING#

DATESIGNATURE

NUMBER OFFICIAL

AREA ESCORT

TYPE AREA

CONCUR

DATE

OFFICIAL'S SIGNATURE

COORDINATING/APPROVING

YES NO

AF IMT 2586, 19981001, V2 (REVERSE)

IV. RESTRICTED/CONTROLLED AREA COORDINATION

V. RESTRICTED/CONTROLLED AREA BADGE ISSUE

NUMBER OFFICIAL

AREA

TRANSACTION

BASIC BADGE

EXCHANGE BADGE #1

EXCHANGE BADGE #2

CARD NUMBERFORM TYPE BADGE NUMBER

ESCORT

TYPE AREA

CONCUR

DATE

OFFICIAL'S SIGNATURE

COORDINATING/APPROVING

YES NO

EXCHANGE BADGE #3

REISSUE #1

REISSUE #2

REISSUE #3

REISSUE #4

REISSUE #5

BADGE ISSUING OFFICIAL

REMARKS

(Typed Name and Signature) APPLICANT VERIFYING RECEIPT OF BADGE DATE(Signature)