Att_(C)_Access_Questionnaire_(Temporary_Access_and_Official_Visit).pdf

CJTF-HOA Base Access Request

Questionnaire (Temporary Access - Less than 3 months) Instructions for CJTF-HOA Base Access Request

In accordance with USAFRICOM Instruction 3300.17 and CJTF-HOA Instruction 1402.1B, all personnel requesting access to CJTF-HOA facilities will submit this CJTF-HOA questionnaire. The questionnaire must be filled out ELECTRONICALLY, printed, and signed by both the sponsor and the person requesting access. The submitting sponsor will then convert the questionnaire to PDF and submit it electronically via email along with scanned copies of requestor identification (ID). The submission will contain at minimum: a copy of ID (National ID or Passports for Local Nationals; Passport for all others) and the scanned/signed questionnaire.

The questionnaire must be typed and filled out in its entirety. Every line must be filled. Do not leave any blank spaces. Use "Not Applicable", "N/A", or "None" where applicable. Incomplete or handwritten Employment Questionnaires will not be accepted.

There are no exceptions to this policy.

General Information:

Date of Application (mm/dd/yyyy):

Why are you requesting access to CJTF-HOA facilities?

Requested access prior? If so, when?:

For what dates are you requesting access (i.e. 1 Jan-30 Jan 2015):

Sponsoring Military Organization:

Sponsoring Military Member (Name & Rank):

Sponsor Contact Information:

Personal Information:

Last:

First:

Middle:

Other Names Used (Birth Name, Nickname):

Marital Status: (Spouse’s Name):

Address (Street Number & Name):

Apt. Number:

City/Village/Province/Region:

How long have you lived at this address (Years/Months):

Date of Birth (mm/dd/yyyy):

Place of Birth:

Religion and Sect:

Nationality: Ethnicity:

Height (Metric/Inch):

Weight (Kilo/Pounds):

Hair Color: Eye Color:

Scars/Marks/Tattoos/Piercings with Locations:

Wear Glasses: ___Yes or ___No

Contact Lens: ___Yes or ___No

Handed: ___Right or ___Left

Contact Information:

Djibouti:

Home Phone: Date Obtained (mm/dd/yyyy):

Cell Phone: Date Obtained (mm/dd/yyyy):

Email Address:

Kenya:

Home Phone: Date Obtained (mm/dd/yyyy):

Cell Phone: Date Obtained (mm/dd/yyyy):

Email Address:

Country of Residence:

Home Phone: Date Obtained (mm/dd/yyyy):

Cell Phone: Date Obtained (mm/dd/yyyy):

Email Address:

Other:

Name of Country:

Home Phone: Date Obtained (mm/dd/yyyy):

Cell Phone: Date Obtained (mm/dd/yyyy):

Email Address:

Employment Background Information:

Are you employed? ___Yes or ___No

If yes, please provide the following information:

Company/Organization:

Job Title:

Job Description:

Job Address/Location:

Work Phone:

Work Cell Phone:

Work Email:

Date Hired:

Supervisor’s Name:

Supervisor’s Phone Number:

Supervisor’s Email Address:

Passport and ID Information:

National Identification (ID Type & Number):

Country of Issuance:

Date Issued:

Expiration Date:

Passport/ID #1:

Country of Issuance:

Date Issued:

Expiration Date:

Passport/ID #2:

Country of Issuance:

Date Issued:

Expiration Date:

Driver License Number:

Country of Issuance:

Date Issued:

Expiration Date:

Other ID Type and Number:

Country of Issuance:

Date Issued:

Expiration Date:

Previous Address Info (10 Year History–Insert lines as needed):

#1

Address (Street Number and Name):

Apt. Number:

City/Village/Province/Region:

How long have you lived at this address (Years/Months):

Reason for Moving:

#2

Address (Street Number and Name):

Apt. Number:

City/Village/Province/Region:

How long have you lived at this address (Years/Months):

Reason for Moving:

#3

Address (Street Number and Name):

Apt. Number:

City/Village/Province/Region:

How long have you lived at this address (Years/Months):

Reason for Moving:

#4

Address (Street Number and Name):

Apt. Number:

City/Village/Province/Region:

How long have you lived at this address (Years/Months):

Reason for Moving:

Foreign Travel (10 Year History):

Country Year of Travel

Reason for Travel

Is there any additional information you would like to provide?

Sponsor: I attest, under penalty of perjury, that I have assisted in the completion of this form and that the information is true and correct.

Print Name & Title: Phone Number:

Sponsoring Military Organization:

Signature: Date (mm/dd/yyyy):

Requester: I attest, under penalty of perjury, that the information I provided is true and correct. Furthermore, I understand my access to facilities in CJTF-HOA may be denied and/or revoked if false information has been provided.

Print Name & Title: Phone Number:

Signature: Date (mm/dd/yyyy):