Attachment 4 Base Access Form.doc

Your Letterhead Here

(Date)

From: (Position, Company Name) To: Assistant Chief of Staff, Operations and Training (G-3)

Via: (Requesting Commercial/Contract Employer)

Subj: DEPOT ACCESS BADGE AND DOD DECAL/PASS REQUEST; IN CASE OF CONTRACT # Ref: (a) CMC Installation Security Access Guidelines, signed 9 Apr 04

(b) DepO 5500.1

Encl: (1) Information Sheet and Vehicle Registration Request

1. In accordance with the references, it is requested that the following personnel, listed on the enclosure(s), be granted access to MCRD/ERR Parris Island in support of Contract #___________________________.

2. The term of this contract is considered valid _____________until _____________ and will require access aboard MCRD/ERR Parris Island. Personnel aboard the installation working in union with this contract will / will not additionally be required access to any “Restricted Area”.

3. Personnel identified in the enclosures have been advised, understand, and expressly consent to a background investigation conducted by representatives of the U.S. Marine Corps using the personal information provided herein.

4. Personnel identified in the enclosures have been advised and understand that while working aboard the installation they are subject to and will:

a. Abide by all local, State and Federal Laws and Regulations governing conduct, registration, licensing and traffic flow.

b. Proceed directly to their work area to begin work and depart directly off the Depot once their work day has ended.

c. Not travel into Military Housing areas unless directed to do so by the scope of the contract and with direct authorization from a supervisor/foreman.

d. Display their contractor ID badge at all times while aboard the Depot.

5. Any questions regarding this matter should be directed to (Contractor Rep), (Company Name), at extension (phone number).

(Contractor Company Authorizing Signature)

ENDORSEMENT

From: (Commercial/Contracting Agency) To: AC/S, Operations and Training (G-3)

Attn: Security Manager

Subj: ACCESS REQUEST

1. Forwarded Approved; recommend issuance of Contractor Badge and DOD Decal/Temporary Pass to be reviewed every 11 months.

Print

Signature

ENCLOSURE (1)

DEPOT CONTRACTOR BADGE APPLICATION

COMPANY REQUIRED INFORMATION

Contractor:

Contract #:

Contract Expiration Date:

Subcontractor:

Subcontractor Expiration Date:

Company Point of Contact (Name/Email/Phone #):

EMPLOYEE INFORMATION

U.S. Citizen: Yes No (Circle One)

PERSON INFORMATION

Last Name:

APPEARANCE INFORMATION

Weight:

LOCATION INFORMATION

Work Phone:

Employer

(Subcontractor Company Name):

Employee Start Date:

Full Home Address (including zip code):

Privacy Act Statement: Information requested above, including the Social Security Number, is collected under the authority provided by Title 5 US Code Sec. 301 and Title 44 US Code Sec. 3101. This information is being solicited in order to allow representatives of the U.S. Marine Corps to make a determination regarding access to Marine Corps Recruit Depot, Parris Island. Disclosure of this information is voluntary, however, failing to provide the information requested above may result in a denial of access to the military facility. Routine use of the information provided shall include, without limitation, all those functions necessary to comply with civil/military administrative and regulatory actions.

Employee’s Signature: ______________________________________________________ Date: _________________

I certify that the above named employee is in our employment and requires a Depot access badge and vehicle pass until the indicated expiration date.

Supervisor Signature: ______________________________________________________ Date: _________________ Requires After Hours Access: YES / NO Requires Access to Depot Housing Areas: YES / NO

DEPOT SECURITY MANAGERS OFFICE USE ONLY

Check Database:

Check Denied List:

Check CLEOC:

Run NCIC Date/Time:

Decision by Security Manager:

CLEOC Narr Added Date/Time:

Badged Date/Time:

ENCLOSURE (2)

FOR OFFICIAL USE ONLY