FC Access Form 2036.pdf

REQUEST FOR A FORT CARSON INSTALLATION ACCESS CONTROL CARD

(Required for all Pass Requests greater than 24 hours)

(Fort Carson Directorate of Emergency Services, Security and Access Control is the proponent agency for use of this form IAW AR 190-13) Privacy Act Statement

Authority: 10 U.S.C. 3013, Secretary of the Army; Army Regulation 190-13, The Army Physical Security Program.

Purpose(s): To support Department of the Army physical security and access control programs; Information Assurance program; to record personal data and vehicle information registered with the Department of the Army; to provide a record of security/access badges issued; to restrict entry to installations and activities; to ensure positive identification of personnel authorized access to restricted areas; to maintain accountability for issuance and disposition of security/access badges and for producing installation management reports.

Routine uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: The DoD 'Blanket Routine Uses' also apply to this system of records.

Disclosure: Disclosure of SSN and other personal information is voluntary; however, failure provide the requested information can result in denial of access to the military installation.

APPLICANT INFORMATION

NAME (Last, First, Middle): GRADE/RANK/STATUS:

SSN: DATE OF BIRTH: GENDER: FEMALE

DRIVER'S LICENSE#: ORGANIZATION/UNIT:

ORGANIZATION/UNIT PHONE#: RELATIONSHIP TO SPONSOR:

E-MAIL ADDRESS:

REQUESTED CARD

NON-DOD CONTRACTOR FOREIGN NATIONAL AF/NAF VENDOR FAMILY CARE PROVIDER

REQUESTED DATE(s) AND TIME(s) OF VISIT:

CONTRACT PERIOD (FROM/TO DATES) (CONTRACTOR/VENDOR USE AS APPLICABLE):

JUSTIFICATION FOR CARD:

BENEFICIARY INFORMATION

NAME (Last, First, Middle): GRADE/RANK/STATUS:

ORGANIZATION/UNIT: ORGANIZATION/UNIT PHONE#:

E-MAIL ADDRESS:

GOVERNMENT SPONSOR

I certify that the applicant meets the justification requirements as indicated above for access privileges. Furthermore, I certify that the applicant requires frequent and repeated access as defined above in support of the beneficiary or Fort Carson.

SPONSOR’S NAME AND ORGANIZATION

RANK or TITLE/PHONE NUMBER SPONSOR’S SIGNATURE

INSTALLATION ACCESS CONTROL OFFICE USE ONLY

ISSUING OFFICIAL:

APPROVED

PRINT ISSUING OFFICIAL'S NAME ISSUING OFFICIAL'S SIGNATURE

DISAPPROVED

DATE

FC FORM 2036-E, MAR 2020

MALE