JL-5_JB2 Form 0-180 Summary Sheet for Visitor Pass.pdf

SUMMARY SHEET FOR VISITOR PASS REQUESTS TO ACCESS

JOINT BASE PEARL HARBOR-HICKAM PROPERTIES

1. All information must be typed; only signatures with dates can be written and must be in BLACK or BLUE ink, digital CAC Card signatures are accepted and highly encouraged.

2. All names below must be listed as Last Name, First Name, MI, to match individual submitted SECNAV 5512-1 form in order to conduct proper background check. Names without a submitted SECNAV 5512 form will not be processed.

3. Sponsor listed below must also be listed as Sponsor in Block 25 of ALL accompanying SECNAV 5512-1 forms.

4. Location or address visiting/accessing must be properly annotated. (No access will be allowed to visitors to use automatic vehicle gates)

5. Depending on request, expiration date WILL NOT exceed one year.

6. Applications must be reviewed/received NO LATER THAN 14 Business Days prior to requested start date (processing times may vary).

7. Applications with incomplete forms, forms with errors, or if additional paperwork needed will be returned for correction.

8. Processing times for all applications does not begin until all paperwork is verified and received by Pass and ID Personnel.

9. Requester and/or Sponsor will be e-mailed at the address provided below for final disposition of applications unless otherwise specified. Personnel must pick up their badges within 30 days after notified ready for issuance. Applications will be discarded after 30 days and a new one must be submitted.

From: Issue Location: Pass Type: Pass Start Date: Pass Expiration Date:

(Unit/Organization) (DBIDS select Nimitz): (1 year or less):

Pass Days: Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Daily Start Time: Daily End Time: Location or Address:

Justification:

(Specific reasons justifying access to JBPHH, ability to sponsor, to have unescorted access, access above FPCON Bravo or for specific days/times, etc)

Visitor Listing:

(All names below must have an accompanying SECNAV 5512 filled out in order to conduct proper background checks)

Last Name First Name MI PID Last Name First Name MI PID

Grade Last First MI Phone

Email Signature Date

Last First MI Phone Sponsor:

Government/Military Employer/ Lease Signer Signature Date

Last First MI Phone

Signature Date

Last First MI Phone Command:

Required for ALL requests exceeding 30 days Signature Date

JBPHH/JB2 Form 0-180 (01 May 2020) PASS & ID WEBSITE: https://cnic.navy.mil/regions/cnrh/installations/jb_pearl_harbor_hickam/om/pass_and_id.html

Housing:

Required for authorized residents and all house guests over 30 days

Grade

Email

Grade

Email

Grade

Email

Requester:

May be sponsor, site manager or contractor

1297921645A Highlight

PRIVACY ACT STATEMENT

AUTHORITY: Section 3101, Title 44, US Code, 5 USC 552A PRINCIPAL PURPOSES: The purpose of requesting personal information is to assist security personnel in developing records to document contractor employee suitability for access to Joint Base Pearl Harbor-Hickam, Hawaii to work under Navy, Air Force, or local contracts. The social security number and date and place of birth are necessary to identify persons, maintaining records, and for criminal history/background checks.

ROUTINE USES: This information may be used to determine suitability of persons desiring access to Joint Base Pearl Harbor-Hickam as well as for other lawful purposes including law enforcement and litigation.

DISCLOSURE IS VOLUNTARY: 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 contract while serving in the capacity of prime contractor or subcontractor/supplier/employee.

Last Name First Name

Visitor Listing (continued) MI PID Last Name First Name MI PID

Date received: Grade:

Pass and ID use Only

Last: First: