Attach_4_MCIPAC-MCBB Group Access Pass Escorted (Rev. 4-22).pdf

MCIPAC-MCBB GROUP ACCESS PASS ESCORTED (ｴｽｺｰﾄが必要)

THIS FORM MUST BE TYPED; NO ADDITIONS TO THE LIST WILL BE ACCEPTED ONCE APPROVED.

GROUP PASS MUST BE SUBMITTED TO EACH CAMP WHERE ACCESS IS REQUIRED.

Kinser Foster/Lester Courtney/ McTureous Hansen Schwab Futenma

1. Sponsor Name (スポンサー) (Last, First, MI): 2. Rank: 3. Duty Phone: 4. Unit/Organization:

As the sponsor, I understand the guidelines below and that I am responsible for my guests' conduct at ALL times while aboard the installation.

X

9. Sponsor’s Signature

* Persons under the age of 18 must be accompanied by their parent/guardian, or have in their possession a signed Permission Slip. 入域者が18歳未満の場合

は保護者または世話人が同行するもしくは入域についての委任状が必要。* If the number of visitors exceeds the space allotted, a separate request must be submitted for remaining group members. 入域者の人数が以下の欄に入らない場合は別紙に記載すること。* This form is not valid for Designated Third Country Nationals (USFJI 31-204). この書式は指定された第3国の者には適用されない。* Individuals must possess a suitable means of identification while on or attempting to gain access to the area(s) listed herein. Failure to do so may result in the denial of access or removal from the area. 入域者はここに記載されている場所に入域する、又 はしている間は身分証明書を形態すること。これに反した場合、入域を却下されたり、又は退去を命じられることもある.

DO NOT MARK BELOW THIS LINE

Dates Authorized （期間） Gate(s) Authorized （通行許可されたゲート） Approval Signature (米軍側サイン) to

Times Authorized （時間） Not Valid Without Original Signature & Stamp Access may be authorized by the Camp Commander or his/her designated representative ONLY to

This document contains CONTROLLED UNCLASSIFIED INFORMATION (CUI) - PRIVACY SENSITIVE: This form may contain personal data or legally privileged information protected from disclosure by the Freedom of Information Act (FOIA), 5 USC Section 552, and/or the Privacy Act, 5 USC Section 552a. Reviewing, copying, distributing, or otherwise disseminating this form is strictly prohibited without the recipient having a valid need to know in the performance of official duties or the express permission of the sender. If you have received this document in error, please notify the owner/creator or your Privacy Act Officer immediately. ANY MISUSE OR UNAUTHORIZED DISCLOSURE

MAY RESULT IN BOTH CIVIL AND CRIMINAL PENALTIES.

MCIPAC-MCBB/PMO/5512/1 (Rev. 04-22) PREVIOUS EDITIONS ARE OBSOLETE AEM Forms Designer

Visitor （訪問者） Vehicle (車両) Last Name* First Name* Citizenship* Age

(if <18) Make Model Color License Plate*

5. Purpose of Visit: 6. Destination:

7. Dates/times Requested: 8. Gates Requested:

ADMIN NO.

Ref: MCIPAC-MCBBO 5512.2A

Kinser

6.5.0.20211215.1.13