Attachment 3 - VisitorForm Kirtland AFB.pdf

February 2017

KIRTLAND AFB

SHORT TERM VISITOR PASS

PRE-NOTIFICATION FORM

SPONSOR INFORMATION

FIRST NAME

LAST NAME

FULL SSN

ORGANIZATION

CONTACT PHONE

This form must be completed and submitted to the Gibson Visitor Control Center (VCC) or Truman VCC no earlier than 72 hours prior to visitor arrival. Upon form submittal, VCC personnel will validate sponsorship authority and verify the form is completed correctly. The visitor must report to the designated VCC with a valid government issued picture ID card (DL, State ID, etc.) to obtain a pass. This form must be submitted prior to visitor arrival or the sponsor will be required to report to the VCC to obtain a pass for the visitor.

VISITOR INFORMATION (one visitor per form)

FIRST NAME

MIDDLE NAME

LAST NAME

DATE OF BIRTH

DRIVER LICENSE STATE

US CITIZEN YES___ NO___ (If no, list country of citizenship)___________________________

PASS INFORMATION

The duration of this pass cannot exceed 30 days. If the visitor has 3 or more passes totaling 30 days or more within a 90 day period, the sponsor and visitor will be required to follow the procedures to obtain a long term pass.

DESTINATION(S)

START DATE

END DATE

ACCESS TIMES (i.e. 0730-1630)

SPONSOR ACKNOWLEDGMENT

I understand that I am responsible for the actions of all visitors I sponsor onto the installation. I understand that failure to comply with instructions could result in my loss of sponsorship privileges. If you need more information, please contact me at the above number.

DATE SPONSOR SIGNATURE

PRIVACY ACT STATEMENT: The contents of this/these document(s) shall not be disclosed, discussed, or shared with individuals unless they have a direct need-to-know in the performance of their official duties. Deliver this/these document(s) directly to the intended recipient. DO NOT drop off with a third party. ROUTINE: To request and record the issuance of a Visitor when the use of another form is not authorized. Failure to provide any of the information requested may result in non-issuance of the Visitor Pass. This information is necessary for validation of the sponsor’s identity and determination of entry eligibility of the visitor onto Kirtland Air Force Base. Failure to provide this information may result in a non-issuance determination by the issuing authority.