USFK_FORM_82-E_Application_for_Installation_Access2015.pdf

USFK FORM 82-E, 11 DEC 14

APPLICATION FOR INSTALLATION/BASE ACCESS

(USFK REG 190-7)

SEE PRIVACY ACT STATEMENT ON PAGE 2

DATE

SECTION I- TO BE FILLED OUT BY SPONSOR AND APPLICANT (TYPE OR PRINT)

1. NAME (LAST, FIRST, MIDDLE) 2. SEX 3. a KID/SSN OR PASSPORT 3.b DoD ID Number

4. DOB (YYYYMMDD) 5. HEIGHT 6. WEIGHT 7. HAIR 8. EYES 9. GLASSES

YES

10. POB (CITY/COUNTRY)

11. ADDRESS & PHONE NO.

11.a. CURRENT ADDRESS & PHONE NO. (ST NO., CITY & PROVINCE) 11.b. PERMANENT ADDRESS & PHONE NO. (ST NO., CITY & PROVINCE)

12. ACCESS REQUIRMENTS (If USFK or EUSA-wide; Special processing required) 12.a. ACCESS AREA 12.b. FPCON (A,B,C,D) 12.c. ESCORT PRIVILEGES

YES NO

PERS Vehicle

12.d. HOURS 12.e. DAYS

12.f. PASS TYPE

EMPLOYEE ROK MILITARY SPONSORED GUEST SHORT TERM VISITOR

CONTRACTOR ALLIED NATION DRIVER (RED) PERSONAL EMPLOYEE

SPOUSE (RED) MIL FAMILY MBR DoD FAMILY MBR CONTRACTOR (719R) VOLUNTEER DCP (RED) (Non-dependant)

12.g. STATUS

INITIAL RENEWAL UPDATE

12. h. DoD CAC

YES NO

13. SPONSOR INFORMATION

13.a. SPONSOR (FULL NAME/RANK or GRADE) 13.b. SPONSOR FULL SSN 13.c. SPONSOR ORG & PHONE NO.

14. JUSTIFICATION FOR INSTALLATION/BASE ACCESS (ATTACH COPY OF KID CARD OR PASSPORT, PRIVIOUS PASS, AND DoD CAC as applicable)

(FPCON Level, escort authorization, Access Area, and days/hours of access must be addressed in justification)

SPONSOR STATEMENT OF UNDERSTANDING

I fully understand my responsibilities as a sponsor for the control of the person identified at the top of this application. All information submitted is true and correct to the best of my knowledge. I further understand that it is my responsibility to ensure that I notify the Installation Pass & ID Office of any change in my status as a sponsor or any knowledge of misuse of the pass to be issued. It is my responsibility to ensure that the pass is returned to the Installation Pass & ID Office if it is not renewed, upon termination of employment or services being provided; or for short term visitors or personal service employees, prior to my DEROS. Failure to comply with these requirements may result in adverse administrative or legal action against me.

15. SPONSOR SIGNATURE DATE

FEMALE

MALE

NO

SECTION II - TO BE FILLED OUT BY DOD SPONSOR, CPOC OR USACCK

NAME (LAST, FIRST, MIDDLE) KID/SSN OR PASSPORT

16. GRADE/RANK 17. JOB TITLE 18. DATE OF EMPLOYMENT

19. UNIT/AGENCY/COMPANY ADDRESS/PHONE NO. 20. CONTRACTING OFFICER / PHONE NO.

21. CONTRACT NO.

22. CONTRACT PERIOD (YYYYMMDD-YYYYMMDD)

SECTION III – REQUESTING AUTHORITY

I HAVE REVIEWED THIS APPLICATION AND ITS SUPPORTING

DOCUMENTATION AND I ENSURE IT MEETS THE PROVISIONS OF

USFK REG 190-7.

Recommend Approval Disapproval

SIGNATURE, TYPED NAME, GRADE, DUTY TITLE

SECTION IV – TO BE FILLED OUT BY PASS & ID OFFICE

23. BACKGROUND CHECK WITHIN LAST 3 YEARS? YES NO

DATE REQUESTED DATE COMPLETED

23.a. Local Law Enforcement 23.b. KNP 23.c. US Embassy (if applicable)

24. DEROGATORY INFORMATION YES NO

(If Yes) Date Provided Approval Authority

25. IS APPLICANT A DESIGNATED COUNTRY PERSON (DCP)? 26. IS THIS PASS APPLICATION IAW USFK REG 190-7?

YES NO

27. DATE PASS ISSUED 28. PASS EXPIRATION DATE

I HAVE REVIEWED THIS APPLICATION TO ENSURE INFORMATION AND DOCUMENTATION

REQUIRED FOR AN APPROVAL DETERMINATION ARE ENCLOSED AND IAW USFK REG 190-7.

29. SIGNATURE OF PASS & ID SECTION CHIEF OR NCOIC DATE

SECTION V – APPROVAL AUTHORITY

I HAVE REVIEWED THIS APPLICATION AND ITS SUPPORTING

DOCUMENTATION AND I ENSURE IT MEETS THE PROVISIONS OF USFK

REG 190-7.

Approved Disapproved

SIGNATURE, TYPED NAME, GRADE, DUTY TITLE

PRIVACY ACT STATEMENT

1. AUTHORITY: Title 10, USC, 3012(g).

2. PRINCIPAL PURPOSE(S): Use of Social Security Number or Korean Identification number is an additional means of identification of individuals.

3. ROUTINE USES: An individual’s Social Security Number or Korean Identification number, together with name and other personnel identifying data, may be used for the collection of derogatory information on file within DOD, host nation, and other Law Enforcement Agencies in determining an individual’s suitability for access to USFK installations in Korea.

4. MANDATORY OR VOLUNTARY DISCLOSE AND EFFECT ON INDIVIDUALS NOT PROVIDING INFORMATION:

Disclosure of information is voluntary. Failure to provide required data may result in denial of access to USFK installations.

USFK FORM 82-E, 11 DEC 14

YES NO

INSTRUCTIONS FOR COMPLETING USFK FORM 82-E (APPLICATION FOR INSTALLATION PASS)

SECTION I - Sponsor or Applicant will:

1. NAME (Name information must match national registry, ex. SSN/KID Administrations)

2. SEX (Check appropriate block)

3. KID/SSN or Passport; (Input correct numbers/information)

4. DOB; (4 DIGIT Year, Month, date format, ex. 19751005)

5. Height ; (Use inches)

6. Weight; (Use pounds)

7. Hair Color

8. Eye Color

9. Glasses, Yes or No; (Indicate Contacts if worn)

10. POB; (ex. Seoul, Korea or Atlanta, GA USA

11. Current Address in Korea (Full Civilian Off-Post Address, if DOD, Full APO Address)

12. Access requirements:

12.a. Input Access Area, (EX. YONGSAN, AREA 1A, Osan). Must be specific & for Official duty only.

NOTE: Request for USFK or EUSA - wide Access require Approval from the USFK Deputy Chief of Staff. Request for this type of access will be forwarded through the CFC/USFK Provost Marshall Office, Security Division (FKPM-S), for processing and submission to the USFK DCofS.

12.b.c.d.e. Input desired FPCON, ESCORT PRIVILEGES, TIME and DAYS access is required.

12.f.g. Select type of Pass, Permanent or Temporary: indicate Initial, Renewal or Update of desired Pass

(Include photocopy of current Pass, KID Card or Passport w/photo)

SHORT TERM VISITS. Personnel sponsored by US or DOD personnel may use this form when requesting this type of access. In Block #14, specify purpose, time period of visit; not to exceed 60 days, and provide sponsor's information, visitor's personnel ID number (SSN or Passport #).

13. Sponsor Information (Provide all required information)

14. JUSTIFICATION; Provide detailed information that supports that type of Access requested. List specific locations and frequency of access.

(ex. Travel to CRC, Cp Casey, and Osan 2 X weekly to deliver Supplies) SPONSOR WILL READ and SIGN STATEMENT OF UNDERSTANDING.

SECTION II - DOD SPONSOR, CPOC OR USACCK will:

16. Provide current Grade/Rank of Applicant or Contractor

Blocks 17, 18; Provide Official Job Title and date began employment with USFK.

19. Input Official Unit or Civilian Agency Address and Telephone number. (Use USFK APO or local Korean Address)

Blocks 20, 21, 22; (This information is required data for all contractor applicants)

(If applicant is a contractor, SF Forms 26 and 30 or USFK Form 175-R MUST be submitted with this application.)

SECTION III - REQUESTING AUTHORITY will:

Indicate APPROVE OR DISAPPROVE and sign USFK Form 82-E in Section III

SECTION IV - PASS & ID Office or PMO will:

Blocks 23-28; Review Application and supporting documents. Answer YES or NO. Input correct dates regarding Background Checks and Pass pass issue data.

29. Signature of Pass & ID Section Chief or NCOIC that reviewed of application for completeness. Indicate whether documents

SUPPORT or DO NOT SUPPORT approval of this pass request.

SECTION V - APPROVING AUTHORITY will:

Indicate APPROVE OR DISAPPROVE and sign USFK Form 82-E in Section V.

USFK FORM 82-E, 11 DEC 14 (INSTRUCTIONS) PAGE 3 OF 3