FORT CUSTER ACCESS REQUEST FORM_2024 VERSION.pdf
PDF 326 KB Posted
- Attached to
- 511/24221. JLM; Fort Custer - ARC Flash Study
- Solicitation number
- RFP 171 240000002399 4
- Issued by
- Michigan
About this file
This is an Installation Access Request Form for Fort Custer Training Center (FCTC), a Michigan Army National Guard facility. The form is used to document contractor and employee suitability for access to the installation and must be completed by individuals requiring regular and frequent access to perform official duties. The form collects personal identifying information including name, driver's license number, date of birth, place of birth, and work authorization verification through DHS Form I-9. Requestors must specify the dates of access needed and indicate whether escort privileges are required. The form requires a sponsoring organization representative or authorized Fort Custer personnel to complete the sponsorship section, providing their name, title, rank, contact information, and signature. Completed forms should be submitted to FCTC Range Control (Building 3650) via email at ng.mi.miarng.mbx.fctc-range-control@army.mil or phone at 269-285-7559, with copies also sent to SFC William Burns or FCTC-DK Security/Operations at the front gate.
The form operates under the authority of Army Regulation 190-13, Directive-Type Memorandum 09-012, and Title 18 USC Section 1382, with privacy protections governed by the Privacy Act of 1974. Access is restricted to individuals without a Common Access Card (CAC) who require installation entry for contractor or employee duties. The form incorporates a consent statement whereby individuals agree to vehicle searches upon entry and acknowledge that Fort Custer assumes no liability for towing or impoundment charges. Disclosure of requested information is voluntary; however, failure to provide required information will result in denial or withdrawal of access privileges. Criminal history information, including felony convictions, must be disclosed, and information collected may be released to law enforcement agencies or the Department of Justice as necessary.
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Text version
FORT CUSTER ACCESS REQUEST FORM
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
Date:
Complete this form and return to your Fort Custer sponsor.
Section I. PERSON TO BE GRANTED ACCESS
1. NAME (Last, First, Middle) 2. DRIVER’S LICENSE #/State 3. DATE OF BIRTH
5. Company/Organization Name: 6. Company Point of Contact: 7. POC Phone Number:
8. POC Email Address: 10. Dates of Access Requested:
From: To:
12. Escort Privileges Requested:
YES NO
Section II. PLACE OF BIRTH
1. CITY 2. STATE (If applicable) 3. COUNTRY
4. Has this individual been convicted of a felony? 5. This individual has completed a DHS Form I-9, work authorization has been verified and a copy is on record.
YES NO
Section III. WARNING: CONSENT TO SUBJECT SEARCH/SEIZURE, VEHICLE TOWING, REIMBURSEMENT, IMPOUNDMENT
By accessing the installation, you agree that by entering Fort Custer Training Center, you give your consent to search of your vehicle. If your vehicle is towed or impounded, Fort Custer is not responsible for charges that occur.
Section IV. FORT CUSTER SPONSORING ORGANIZATION OR PERSONNEL AUTHORIZED TO SPONSOR
THIS SECTION TO BE COMPLETED BY FCTC SPONSOR
Last Name:
First Name:
Title/Rank:
Phone: Email:
Signature:
***Drop off (or email) completed form to: FCTC Range Control (Bldg 3650) @ ng.mi.miarng.mbx.fctc-range-control@army.mil 269-285-7559; SFC Burns, William: william.h.burns24.mil@army.mil 269-282-7556, and FCTC-DK Security/Operations (Front Gate):
fortcuster@dksecurity.com 269-565-3319.***
Section VI. PRIVACY ACT STATEMENT Authority: Army Regulation 190-13, “Army Physical Security Program”, 2019 June 27, 2011; Directive-Type Memorandum 09-012, “ Interim Policy Guidance for DoD Physical Access Control”, 2013 March 19, Title 18, USC Section 1382.
PRINCIPAL PURPOSE(S): The purpose for requesting personal information is to assist Access Control personnel in documenting contractor/employee suitability for access to Fort Custer. Date of birth and Driver’s License information is necessary to identify the person and records. Information collected on this form may be released to law enforcement agencies engaged in the investigation or prosecution of a criminal act or the enforcement or implementation of a statute, rule, regulation or order; to any component of the Department of Justice for the purpose of representing the DoD.
INTENDED USE: For all personnel who are not authorized a Common Access Card (CAC) and require regular and frequent access to the installation in performance of their official duties.
DISCLOSURE: Disclosure of requested information is voluntary; however, failure to provide information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the Army contract while serving in the capacity of prime contractor or subcontractor/supplier employee.
INSTALLATION ACCESS REQUEST FORM, UPATED 14 FEB 2024 Page 1 of 1
YES NO N/A
Reason for access:
| NAME Last First Middle: |
| 2: |
| 5 CompanyOrganization Name: |
| 6 Company Point of Contact: |
| POC Phone Number: |
| 8 POC Email Address: |
| 2 STATE If applicable: |
| 3 COUNTRY: |
| First Name: |
| TitleRank: |
| Text5: |
| Text6: |
| Text10: |
| Date11_af_date: |
| Phone: |
| Email: |
| Date12_af_date: |
| Date13_af_date: |
| Date14_af_date: |
| Text1: |
| Escort: Off |
| Felony: Off |
| I-9: Off |
| THIS SECTION TO BE COMPLETED BY FCTC SPONSOR: |
| REASON FOR ACCESS: |
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