JL-3 N6945022R0050_GuestSponsorshipRequest.pdf

ACTIVE RESERVE DEPENDENT RETIRED CIVILIAN

FOR OFFICIAL USE ONLY - PRIVACY SENSITIVE - Any misuse or unauthorized disclosure can result in both civil and criminal penalties. PRIVACY ACT STATEMENT

AUTHORITY: Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act. PRINCIPAL PURPOSE: To record names, signatures, and Social

Security Numbers for the purpose of validating the trustworthiness of

Individuals requesting access to Department of Defense (DoD) systems and information. NOTE: Records will be maintained in paper form. ROUTINE USES: None.

DISCLOSURE : Disclosure of this information is voluntary; however, failure to provide the requested information may impede, delay or prevent further processing of this request.

NAS CORPUS CHRISTI

GUEST SPONSORSHIP REQUEST

WORK NUMBER:

HOURS OF EVENT

PLEASE CHECK THE APPROPRIATE BOXES TO

INDICATE YOUR AFFILIATION TO THE BASE

NUMBER OF GUESTS

LOCATION

TYPE OF FUNCTION:

DATES OF EVENT

HOME/CELL PHONEFULL SSN #

NAME

DRIVER LICENSE &

STATE OF LICENSE

DATE OF BIRTH

Guest sponsors are responsible for any abuse that may arise from the guest's use of their credentials to access this installation. The guest sponsorship request takes (3 )working days to process. You should feel confident that a guest will honor and use this privilege in a responsible manner. Please take the time to communicate all of the policies that you observe while on this installation with each guest. Please be advised that your guest sponsorship privileges can be revoked if a guest is found in violation of base policies or federal statutes.

Sponsor's Signature X__________________________________________

DATE:

HOME NUMBER

CELL NUMBER

TO: SECURITY OFFICER, NASCC

SIGNATURE OF APPROVAL: Martin Wheeler

BY DIRECTION OF SECURITY OFFICER

X__________________________________________