Attachment M - Installation Access Request Form.pdf

2. RANK:

U.S. NON U.S.

3.AREAS REQUESTED: 4.DATES REQUESTED:

F 1 C E

6.GUEST INFORMATION:

SSN

(U.S Personnel Only)

6.DATE: (DD-MMM-YY)

6.DATE: (DD-MMM-YY)

Received by: ITAF check: PRIVACY ACT INFORMATION: The information in this form is FOR OFFICIAL USE ONLY. Protect IAW the Privacy Act of 1974

(LAST, FIRST MIDDILE INITIAL)

2.U.S. Citizen/NON U.S. Citizen (choose one)

DISAPPROVEDAPPROVED

5. SIGNATURE:4.APPROVAL OF REQUEST:

II. Visitor's Information

3.DUTY PHONE:2. GRADE:1. NAME: (Last, First, Middle Initial)

1. NAME: (Last, First, Middle Initial)

I certify the Requester in Block I. based on personal knowledge and available documentation is in a status eligible for requesting an IAR with Aviano AB, Italy.

(Must be Stationed at Aviano AB)

IV. ITAF Security Forces Commander

3.DUTY PHONE:

APPROVED DISAPPROVED

4. APPROVAL OF REQUEST 5. SIGNATURE:

Attach additional list of guests names and information to page 2. Attach a copy of EACH passport to the end of this document.

7.REASON FOR ACCESS:

If you require additional space for justification use page 3.

III.Commander/Director

2. GRADE:

Document Type & ID Number Vehicle Make/Model & License Plate (If Applicable)

1. ESCORTED / UNESCORTED (choose one)

5.TIMES REQUESTED:

TO

ESCORTED UNESCORTED

TO

4. DSN / CELL PHONE: 5.PRIMARY EMAIL ADDRESS:

By signing this form I understand that if I request an escorted pass, I must be with my guest at all times. If I lose contact with my guests I will contact Security Forces at 632-7200 to report the incident. I confirm that all information on this request is accurate and correct.

7. REQUESTER'S SIGNATURE:

6.SPONSORING UNIT:

DISCLOSURE: Voluntary. Not providing SSN may cause form to not be processed.

I.Requester's Information 3.DATE REQUEST SUBMITTED: (DD-MMM-YY) PLEASE SUBMIT 30 DAYS PRIOR TO START DATE1. Name: (LAST, FIRST MIDDILE INITIAL)

INSTALLATION ACCESS REQUEST

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 United States Code (U.S.C.) 8013, Secretary of the Air Force; AFI 36-2406, and Executive Order 9397 (SSN), as amended.

PURPOSE: Used to request installation access and conduct necessary background checks.

ROUTINE USES: May specifically be disclosed outside the DoD as a routine use pursuant to U.S.C. 552a(b)(3). DoD Blanket Routine Uses apply

CAPUTO, DOMENICO T.Col/OF-4 632-4731