MICC Access_Request_Template.docx
DOCX document 107 KB Posted
- Attached to
- NTC 25-09 Requirement - Light Sets x 64 Federal contract opportunity
- Solicitation number
- W911YN25QA026
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| File | Type | Posted |
|---|---|---|
| Solicitation - W911YN25QA026.pdf |
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Text version
DEPARTMENT OF THE ARMY
YOUR AGENCIES LETTER HEAD
FORT IRWIN, CA 92310-5000
REPLY TO
ATTENTION OF
(Office symbol) 7 July 2023
MEMORANDUM FOR DIRECTORATE OF EMERGENCY SERVICES
SUBJECT: Fort Irwin Contractor/Commercial Vendor Access Request
1. This office requests that the below named individual(s), employed by (Company/Organization name), be granted access to Fort Irwin. The purpose for access is (state purpose, project name etc.) conducted at (e.g. Bldg. #, site location).
| PRIVACY ACT STATEMENT | ||
| AUTHORITY: | HSPD-12 | |
| PRINCIPAL PURPOSE: | To record names, signatures, and other identifiers for the purpose of validating the trustworthiness of individuals requesting access to NTC & Ft. Irwin, CA. NOTE: Records may be maintained in both electronic and/or 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. |
| NAME |
| DL/ID #, State |
* See below for Non-REAL ID Act Compliant States Period of Required Access
| Commencing |
| Ending |
| Last |
| First |
| MI |
| mm/dd/yyyy |
| mm/dd/yyyy |
| Johnson |
| Robert |
| A |
| U5174444, CA |
| 08/14/2017 |
| 10/27/2017 |
* REAL ID Act. Unless they bear the imprint `Enhanced Driver's License/Enhanced Identification Card', state issued DLs and ID's from states which are non-REAL ID Act compliant or do not have a current extension must be accompanied by a supplementary identity document for installation access or an escort will be required.
Click here to determine the status of each state/territory. (https://www.dhs.gov/current-status-states-territories) Click here for a list of acceptable supplementary identity documents.
The following are other acceptable forms of ID for visitor installation access: DA Form 1602 (Civilian ID Card and Gold Star Family), a valid US passport or passport card, or a Transportation Worker Identification Credential (TWIC). Form I-766 with a photograph (Employment Authorization Document) or a valid foreign passport with I-551 stamp or with INS Form I-94 or I94A are also acceptable forms of ID however these visitors require 24/7 escort by their sponsor. DLs/ IDs with the imprint `Not for Federal Identification' ARE NOT acceptable forms of ID and an escort will be required.
1. POC is Mrs. Joan Smith at joan.r.smith.civ@mail.mil or 760-380-XXXX.
| Digital/Original Signature |
| Full Name |
| Title |
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