71 SFS DBIDS Application.pdf

Installation Access Application (This Form is Subject to the privacy Act of 1974)

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 8013 and E.O. 9397 (SSN)

PRINCIPAL PURPOSE: Used by the Security Forces for issuing ID cards and restricted of controlled area badges which authorize entry into certain areas. Some organizations may routinely keep copies of the above documentation in order to maintain control over persons authorized entry into certain areas.

accountability documents are used to insure proper control over various forms utilized in these functions.

ROUTINE USE: To request and record the issuance of computer generated VAFB Contractor/Visitor Identification Card and to request and record issuance of an identification credential when the use of another form has not been specified.

DISCLOSURE: Information requested on the form is voluntary. Failure to provide any of the requested information will result in non-issuance of the identification credentials.

I hereby acknowledge receipt of the credentials indicated by my signature below and I am fully aware of my responsibilities pertaining to their use. I will promptly return all credentials when they are not needed for my assigned duties or upon request by proper authority.

NOTICE: While on the installation all personnel and property under their control are subject to search.

To: 71 SFS/VCC CONTRACTOR/BUSINESS REQUIRING ACCESS

NAME (Last, First, Middle) RACE Date of Birth (YYYY-MM-DD) State (Birth place)

DRIVERS LICENSE/STATE ID # ISSUING STATE LAST FOUR OF SSN CITIZENSHIP (Country)

HEIGHT WEIGHT PHONE #

HOME ADDRESS

SIGNATURE OF APPLICANT DATE SIGNED (YYYY-MM-DD)

CERTIFICATE OF AUTHORIZED REQUESTING OFFICIAL (I.E., MILITARY,USAF EMPLOYEE/DOD)

I certify that the applicant has an official/authorized need for the credentials requested and has been briefed on its proper use. I will notify Security Forces immediately for proper action when a contractor/visitor refuses to return DBIDS card upon termination, completion expiration or when person no longer requires access.

NAME (Last, First, Middle)/DUTY TITLE ORGANIZATION DATE GIVEN (YYYY-MM-DD)

WORK PHONE # CELL PHONE # SIGNATURE DATE SIGNED (YYYY-MM-DD)

LOCATION OF WORK DAYS OF ACCESS

SUN MON TUE WED THU FRI SAT

HOURS OF ACCESS DURATION OF CARD (I.E. 6 months/1yr)

VCC USE ONLY

ISSUED BY ISSUED DATE (YYYY-MM-DD)

CARD EXPIRATION DATE (YYYY-MM-DD) VETTED/APRROPED BY & DATE (YYYY-MM-DD)