RFP Attachment J.B-3 Access Request Form.doc
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J.B-3 Access Request Form
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COMNAVREGEURINST 5530.2
APPLICATION FOR CNRE INSTALLATION ACCESS PASS
(CNRE INST 5530.2a)
Data required by the Privacy Act of 1974
AUTHORITY: Art. XV, MOU Shell Agreement of 1995; Art VII, Para. 10 NATO SOFA, 10 U.S.C. 5013; E.O. 9397
Principal purpose(s): For identification of U.S. and non-U.S. nationals employed by U.S. Government agencies, contractors, and vendors of non-military agencies of countries in which U.S. personnel have been accommodated when these personnel require recurring access to the accommodations under U.S. control and do not possess other valid entry authorization documents.
Routine use(s): To identify personnel authorized routine or recurring access to installations under U.S. control.
Mandatory or voluntary disclosure and effect on individual not providing information: Voluntary, however, failure to provide any item of information may result in denial of entry onto the U.S.-controlled installations which the CNRE form 5530.2a has been validated.
| Please refer to the instructions on page 3 to ensure that the form is properly filled in. |
| · New application |
· Update
· Renewal
1. To NSA Security Department – Pass & ID Office
2. From
| 3. Applicant name (Last, First, MI) |
| 4. Command Address |
| 5. Address (Company/Organization Name if HN Contractor) |
| 6. Person Category |
| 7. Country of Citizenship |
8. Personal ID Number (From Supporting Document in Block 13)
| 9. Qualification/Title |
| 10. Pay Grade |
11. Place of Birth
12. Mission Essential ( Yes ( No
| 13. Supporting Document expiration date (passport/ID card)(mm/dd/yyyy) |
| 14. Residence permit (Required if not HN) |
( Yes ( No
15. Work permit required (Copy) ( Yes ( No
16. Type pass requested ( HN Contractor ( HN Retiree ( NATO ( Other
17. Date of birth (mm/dd/yyyy)
18. Weight (pounds/kilo)
19. Height (inches/cm)
20. Eye (color)
21. Hair (color)
22. Base required:
( Capodichino ( Support Site ( Carney Park ( Gaeta
23. Limitations/time/day access is requested
( Capodichino 24 hrs Sun-Sat ( Support Site 24 hrs Sun-Sat
( Capodichino 0700-2000 Mon-Fri ( Support Site 0700-2000 Mon-Fri
( Capodichino 1200-2000 Mon-Fri ( Support Site 1200-2000 Mon-Fri
( Capodichino 1600-2400 Mon-Fri ( Support Site 1600-2400 Mon-Fri
( Capodichino 0400-2200 Mon-Sat( Support Site 0400-2200 Mon-Sat
( Capodichino 0400-2200 Mon-Sat( Support Site 0400-2200 Mon-Sun ( Carney Park
24. FPCON
( A ( B ( C ( D
25. Pass expiration date (mm/dd/yyyy)
26. Escort privileges ( Yes ( No
27. Vehicle registration information (With Supporting Original Documents)
| a. License Number |
| b. Country |
| c. Make |
| d. Model |
| e. Year |
| f. Body type |
| g. Color |
| h. POV/Company Vehicle |
28. Company name and telephone number (i.e., Self contractor/Vendors/Delivery Persons Name)
29. Requesting official (must initial before both statements)
____I have reviewed the results of all pertinent available security check certificates as addressed in CNRE INST 5530.2 and verify that there is no derogatory information that would preclude the issuing of an installation pass.
____I verify that the applicant has been informed of the proper purpose and use of the installation pass. I have reviewed CNRE INST 5530.2 and believe this packet is administratively correct and accurately reflects the applicant's access requirements.
| a. Name and Title |
| b. Organization and Telephone Number |
| c. Signature |
| d. Date (mm/dd/yyyy) |
30. To be completed by registrar
a. Issuer Name
b. Date issued
31. Justification for access with reasoning for Date/Time in conjunction with PD.
32. Justifications for escort privileges (i.e., Escorting for work purposes, Etc. Please be specific).
33. Additional Comments
34. Required attachments (check applicable boxes)
| · Residence permit |
| · Defense Clearance Investigation Index (DCII) |
| · Work permit |
| · Security Check Certificates |
35. Additional Endorsing Officials (if required)
| Name: |
| Organization/Title |
| Grade |
| Title |
| Name: |
| Organization/Title |
| Grade |
| Title |
| Name: |
| Organization/Title |
| Grade |
| Title |
| Item 1. To |
| Items 18 and 19. Weight and Height |
| Enter the name of the servicing Pass and ID office. |
| All measurements will use inches and pounds OR kilos and cm’s. |
| Item 2. From |
| Item 22. Base required. |
| Enter the name of the sponsoring official's organization |
| Enter the base required. Depending on the person category, access may be restricted per CNRE Inst 5530.2. Access should be limited to the least amount required. Examples include Capodichino, Carney Park, Gaeta, etc. If CNRE-wide access is requested, include a written justification in Item 31. Justification. The written justification must demonstrate why the applicant requires the level of access in the performance of duties. NATO Members and Department of State and American Embassy person categories are defaulted to CNRE-wide access. No justification required. |
Item 4. Sponsor address
Enter the mailing address of the command. For the person categories Personal-Service Employee, Visitor, and Other also include the requestor's address.
Item 5. Address
Enter the address of the unit of assignment. This address will depend on the applicant's person category. For example, for host national employees, enter the hiring organization's address. For Contractors and Delivery Personnel, enter the address of their company. Visitors should list home mailing address.
Item 23. Limitations/time/day access is required
Enter 24/7 if access is required all the time; otherwise state the specific days of the week and times. NACMS registrars my require justification for liberal access (such as 24/7), therefore sponsoring officials should be prepared to justify this entry.
Item 6. Person Category
| ■DOD ID card holder |
| ■NATO member |
| ■Local National employee |
| ■Host nation military member |
| Item 24. FPCON Condition |
| ■U.S. Contractor |
| ■Member of private organization |
| Enter the FPCON Condition requested. NACMS will establish a default FPCON according to CNRE Inst 5530.2. Sponsoring officials may request a reduction or a one-FPCON increase. Utilize "Alpha," "Bravo," "Charlie," and "Delta" when filling out this item. |
| ■Non-U.S. Contractor |
| ■Visitor |
| ■Personal-service employee |
| ■Official guest |
| ■Delivery personnel i.e Recurring Deliveries or Similar Service Not Associated with a Government Contract |
| ■Department of State and American Embassy Personnel |
Item 25. Pass Expiration Date
| ■Other |
| Enter the desired pass expiration date. The maximum time varies by category group, but should be the end date of the supporting document on which access is based (e.g. contract, orders, etc.). A "Temporary Installation Pass" is valid for up to 90 days. The NIACS registrar will verify the appropriate expiration date prior to creating the Installation Pass. |
| ■Vendor or commercial solicitor |
| ■Host nation government official |
Item 8. Personal ID number
■Enter the ID number or the passport number from the supporting document used. Applicant must have one of the following supporting documents.
| ■Passport |
| Item 26. Escort privileges |
| ■Personal ID card issued by the country of citizenship. (i.e. Carta d'Identità) |
| Enter "Yes" or "No" depending on the applicant's need to have Escort privileges. Sponsors should provide justification for this privilege in Block 32. |
■Military ID card issued by NATO organization or NATO Sending State. (Individuals in the NATO person category must use their NATO issued ID).
Item 27. Vehicle registration information
a. Enter the license plate number exactly as it appears. b. Enter the country from which the license plate was issued c. Enter the make of the vehicle (i.e. BMW, Fiat, Ford, etc.) d. Enter the model of the vehicle (i.e. 320i, Brava, Ranger, etc.) e. Enter the year of the vehicle (yyyy) f. Enter the body type of the vehicle (i.e. sedan, hatchback, SUV, etc.)
g. Enter the color of the vehicle h. Denote the vehicle is privately owned (POV), owned by the Govt (GOV), owned by a company (COMP). If the car is a rental, enter "RENTAL" in this box.
Item 9. Qualification/Title
Enter the qualifications and job title of the applicant.
Item 10. Pay Grade
Enter the grade of the applicant. If the applicant does not fall into a military, U.S. civilian, or equivalent structure, enter N/A.
Item 12. Mission Essential
If the applicant is critical to the accomplishment of the mission during times of elevated Force Protection Conditions (Delta) or during times of natural disasters or other emergencies, check mission essential. Sponsors should take care to limit the number of people they mark "Mission Essential." (For example, during a natural disaster, people responsible for generator maintenance would be "Mission Essential," but NEX employees would not).
Item 28. Company name and telephone number (i.e., Self contractor/Vendors/Delivery Persons Name)
This item is only applicable for Contractors, Delivery Personnel, and Vendors. State the name, title, organization, and telephone number of the sponsoring official. The base NACMS manager must have a copy of the designation of sponsoring officials memorandum from your organization identifying who is authorized to sign installation pass applications.
Item 13. Supporting documentation expiration
| Enter the expiration date of the supporting document (for example, expiration date of passport or Carta d'Identità. For Contractors, enter the end date of the contract if that is prior to the expiration date of the applicant's personal identification.) |
| Item 30. To be completed by NACMS Issuer |
Item 31. Justification for multiple base access
Enter the written justification that clearly states the reason the applicant requires the level of access entered as well as the time and date requested.
Item 14. Residence Permit Required
| If required, check the appropriate box to indicate whether a copy of the residence permit is attached. |
| Item 32. Justification for Escort privileges |
Enter the written justification that demonstrates why the applicant requires Escort privileges in the performance of duties. Please be specific.
Item 15. Work Permit Required
| If required, check the appropriate box to indicate whether a copy of the work permit is attached. |
| Item 33. Additional comments |
Utilize this area for any comments that exceed the space provided.
| Item 16. Type of pass requested |
| Item 35. Additional endorsing officials |
| Check the appropriate box. If an "Installation Pass" is desired, a "Temporary Installation Pass" may be issued pending receipt of all security check certificates available in accordance with the legislation of the receiving State. A "Temporary Installation Pass" is valid for up to 90 days. The restrictions associated with each pass are different for each individual's access requirements. |
| Utilize this space for additional endorsements that may be required beyond those required per CNRE Inst 5530.2 (e.g. requirement per Base Instructions). |
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