JL-4_JB2_FORM_0180_SAMPLE.DOCX

(INSTRUCTIONS)

1. All information must be typed; Last Name, First Name, MI, SSN, Citizenship, Gender, Immigration or Passport Number (if applicable)

2. The only information that can be written is date and signatures at the bottom; original signatures are required at time of application.

3. Must show current vehicle registration, safety inspection, certificate of automobile insurance, and driver’s license and/or other form of picture identification for vehicle(s) and driver(s) when picking up badges & Naturalization Certificate/Permanent Resident Card if applicable.

4. All applications for contractors/vendors must be accompanied by a contractor supplied background check (if required by the contract and if not enrolled in NCACS—i.e., optioning for the one-day pass). The most common background checks submitted by contractors/vendors are Precise Hire and Criminal Watch Dog (Advanced National); however, JBPHH does not endorse any particular background check agencies.

5. This letter must be received by Pass and ID 10 days prior to issuing badges. Personnel must pick up their badges within 30 days of the approval date on this letter. Application will be discarded after 30 day and a new one must be submitted.

6. Place of performance/location visiting must be properly annotated. Wahiawa, West Loch, JBPHH Main Base, etc., may be used if a cover letter is submitted with this application documenting the need for base wide access.

7. Visitor Pass expiration date must be entered. Badge expiration date WILL NOT exceed one year.

8. Incomplete forms or forms with errors will be returned for correction; they will not be processed.

9. The form will be e-mailed to the requester’s e-mail address unless otherwise specified on the form.

1250 SOUTH DRIVE, BUILDING 3455

HONOLULU, HI 96818

FROM: (Sponsor/Organization & Address)

SAMPLE SERVICE, INC.

222 NOWHERE PLACE

LITTLETOWN, HI 99999-8888

VIA NAVFAC PACIFIC

CONTRACT NUMBER AND EXPIRATION DATE

N62742-55-X-2222

22 DECEMBER 2222

BADGE EXPIRATION DATE

(must be 1 year or less)

1 -30 NOVEMBER 2011

DAYS/HOURS WORKED/VISITING

(Example: Daily/All Hours/Mon-Sat/ 0630-2000, etc. (Limit the daily all hours)

MON – FRI

0900 - 1700

PLACE OF PERFORMANCE

(Example: Commissary/BX/Onizuka Village Housing/C-17 Hangar to include Building Number and appropriate Annex of JBPHH)

ALL AREAS PEARL HARBOR

JUSTIFICATION: INSTALLATION OF DIAMOND EYES.

PERSONNEL/VISITOR LISTING

HI 123456789

THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A FALSE, FICTICIOUS OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED STATES CODE, SECTION 1001.

COMMAND ENDORSEMENT:

(required for special, spouse, houseguest, and pickup/drop off passes) Printed Name:

Organization/Number:

Signature/ Date:

HOUSING OFFICE ENDORSEMENT:

(required for houseguest passes) Printed Name:

Housing Office/Number:

Signature/ Date:

Phone & Fax No:

E-mail

CONTRACTOR AND PE/CONTRACT SPEC PHONE # AND CONTRACTOR EMAIL

22 NOV 2011

XXX, NAVFAC PACIFIC

Phone/ E-mail:

472-1111 xxx.xxx@navy.mil

JBPHH/JB2 Form 0-180 1 AUGUST 2011

PRIVACY ACT STATEMENT

AUTHORITY: Section 3101, Title 44, US Code, 5 USC 552A PRINCIPAL PURPOSES: The purpose of requesting personal information is to assist security personnel in developing records to document contractor employee suitability for access to Joint Base Pearl Harbor-Hickam, Hawaii to work under Navy, Air Force, or local contracts. The social security number and date and place of birth are necessary to identify persons, maintaining records, and for criminal history/background checks.

ROUTINE USES: This information may be used to determine suitability of persons desiring access to Joint Base Pearl Harbor-Hickam as well as for other lawful purposes including law enforcement and litigation.

DISCLOSURE IS VOLUNTARY: Disclosure of requested information is voluntary. However, failure to provide information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the contract while serving in the capacity of prime contractor or subcontractor/supplier/employee.

NCIC/BACKGROUND CHECK DATE: ______________ SOURCE USED: _____________________ SRBW CHECK: ___________ TERRORIST DATABASE CHECK DATE:_________________ SEX OFFENDER DATABASE CHECK DATE:_________________

PRINTED NAME/SIGNATURE OF PID REPRESENTATIVE __________________________________________________________

PERSONNEL LISTING (continued)

Sign Sponsor’s Name:

Phone/ E-mail:

JBPHH/JB2 Form 0-180 (Page 2)

SAMPLE THIS IS JUST A SAMPLE SAMPLE