Att 1(j) - Base Access Form

(j) Base Access Form (Seal Beach & Norco)

APPLICATION FOR INSTALLATION ACCESS

Consent to Criminal History I hereby acknowledge understanding, that with voluntary completion of this application, I am requesting access to a Department of Defense (DoD) facility. I hereby authorize Navy Security Force personnel to receive any citizenship and criminal history record information pertaining to me, which may be in the files of federal, state, or local law enforcement agencies.

Privacy Act Statement AUTHORITY: Privacy Act of 1974 (5 USC SECTION 552(A) (7) 41 USC Section 423, 5CFR Section 2635.602, AR 340-21 Title 10 and 37 USC.

PRINCIPLE PURPOSE(S): To enable Military Security and/or Law Enforcement personnel to conduct Citizenship and Criminal Background investigations for civilians requesting access to DoD Facilities.

ROUTINE USES(S): To authorize access to DoD Facilities. Information may be reported to federal, state, and local law enforcement agencies with jurisdictional interest.

DISCLOSURE: Voluntary. Failure to provide requested information will result in denial of access to DoD Facilities.

PRINT CLEARLY FOR TIMELY PROCESSING

NAME (Last) First Middle Gender

|_| MALE |_| FEMALE

Social Security Number Driver License Number Driver License State of Issue Phone with Area Code

ADDRESS (Home)

DATE OF BIRTH

PLACE OF BIRTH (CITY)

STATE OF BIRTH (State)

COUNTRY OF BIRTH

COLOR OF HAIR

EYE COLOR

HEIGHT

WEIGHT

COUNTRY OF CITIZENSHIP

I understand that Federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

Have you ever been convicted of a felony? |_| Yes |_| No

If YES, how many years since conviction? __ ____Years I attest under penalty of perjury, that I am one of the following: ***

|_| A citizen of the United States.

Document Number ____________________________

****All Non-Citizens must provide an Alien Registration Number or Employment Authorization Document (EAD) Number and original cards with this application. Access will not be authorized without this information.

VEHICLE INFORMATION

VEH.. MAKE

VEH. MODEL

VEH. COLOR

LICENSE PLATE #

STATE OF INSURANCE

INSURANCE COMPANY NAME

INSURANCE POLICY NUMBER

INSURANCE EXPIRATION DATE

REASON FOR ACCESS

Reason for Access?

Please check one:

|_| Contractor |_| Delivery |_| Vendor |_| Volunteer |_| Sea Air FCU Employee |_| Other (Specify)

Contractor/Company Name:

Company/Contractor Phone #:

Destination/Area of Worksite on activity:

How long will you need access?

Check one:

|_| 1 Day |_| 3-6 Months |_| 1 Week |_| 6-12 Months

|_| Month

Point of Contact (POC) Name:

POC’s Command:

POC’s Phone #:

PASS

REQUEST

Start Date End Date

I agree to return the badge to the Security Officer upon termination of employment, completion of business transactions, or any other reason that may cancel or alter my privilege for entry to the Station. I hereby agree to and certify that the above information and statements are true. I further agree to abide by all riles and regulations of this activity and subject myself and/or vehicle to search or detention for protection of information or property of the U.S. Government.

Signature: ________________________________________________ Date: _____________________

Application Processing (For Navy Security Force Personnel Only)

VCC Official Name:

Identification Verified:

Identification #:

Photo Copy Retained?

|_| Yes |_| No

Activity Pass Information

VCC Action:

Results:

NWSSB 5530/1

|_| Activity Paper Pass |_| Activity Photo Pass |_| Other:

SORNA

CLEOC

DNEL

Pass Serial Number:

Issue Date:

Expiration Date:

NCIC

|_| Favorable |_| Unfavorable AFC Printed Name:

AFC Signature and Date