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N6247017R5013_Amendment0002_Attachment_(K)_NEW_Access_Questionnaire.xlsx

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ACCESS ROSTER

STARTENDLAST NAMEFIRST NAMEMIDDLE NAMECOUNTRY OF ORIGINID TYPEID COUNTRY OF ISSUEID NUMBERPLATE NOESCORT OR NO ESCORTSPONSOR UNIT/COMPANYPHONE # OF SPONSORSPONSOR NAMEPHONE # OF VISITORREASON FOR VISITUS CITIZEN OR GREEN CARD HOLDERDOB (DDMMMYYYY)PLACE OF BIRTHCURRENT ADDRESS IN DJIBOUTIPREVIOUS ADDRESSCOUNTRIES VISITED OR LIVED IN OTHER THAN DJIBOUTI (LOCATIONS & DATES, LAST 10 YEARS)MILITARY SERVICE (COUNTRY & DATES)ALTERNATE MOBILE PHONE #EMAIL ADDRESSLANGUAGES SPOKENWORK LOCATIONS ON CLDJOCCUPATION ON CLDJPREVIOUS EMPLOYMENT, EMPLOYER, LOCATION AND DATESFRIENDS OR FAMILY EMPLOYED BY US GOVERNMENTFRIENDS OR FAMILY EMPLOYED BY OTHER GOVERNMENT
01/01/1612/31/16DoeJohnQuimbaoDjiboutiNational IDDjibouti123456123ABCEscort RequiredACME INC.+25397865432Jane Doe+25312345678Badge RequestNo31-Dec-1970Ali Sabeh, DjiboutiBalbala, DjiboutiAli Sabeh, DjiboutiSomaliland, 2014. USA, 2010-2012. Ethiopia, 2007-2008Djibutian Army, 1990-1992+25311223344name@email.comSomali, Afari, English, ArabicNew CJTF-HOA HQ BuildingRebar WelderCarpenter, Acme Inc, Ethiopia, 2003-2004Brother, Plumber, Camp LemonnierFather, Djibouti Gendarmerie
12/04/1712/04/17Escort RequiredPWD CLDJ311-824-4374LT Mike AndaTemporary Access

E-MAIL TO: Usn.lemonnier.nafdj-n3at.list.base-acess-control-office@mail.mil

All non-military access requests and documents must be submitted no later than 1600 hrs, FOURTEEN (14) working days (Mon - Sat) prior to the date access is required. Coalition Military access requests must be submitted no later than 1600 hrs, 48 hours (excluding Sundays) prior to the date access is required.

NOTE: For non-Uniformed Services and non-Government Services CAC holding U.S. members and Third Country Nationals, a copy of a government issued passport must be submitted with the Access Request Form.

For Local/Host Country Nationals, a copy of an official government issued ID or government issued passport must be submitted with the Access Request Form. An approved Exception to Policy Request must be obtained and submitted with the above listed documents if access is required prior to the 14 day notification requirement for non-military or 48 hour notification requirement for Coalition Military Forces.

-FAILURE TO SUBMIT PROPER DOCUMENTATION WILL RESULT IN A DELAY OR DENIAL OF YOUR REQUEST.

-FAILURE TO SUBMIT ACCESS REQUEST WITHIN THE PROPER TIME FRAME WILL RESULT IN A DELAY OR DENIAL OF YOUR REQUEST.

National IDEscort RequiredBadge RequestYes
PassportNo Escort RequiredReissue BadgeNo
Temporary Access
Official Visit

&"Courier New,Regular"Updated &D &T Destroy all previous versions &"Courier New,Bold"&20BASE ACCESS ROSTER &"Courier New,Regular"&12FOR OFFICIAL USE ONLY

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