N6274218R1301_JBPHH_FM0180A_10Aug17.pdf

SUMMARY SHEET FOR VISITOR PASS REQUESTS TO ACCESS

JOINT BASE PEARL HARBOR-HICKAM PROPERTIES

All information must be typed The only information that can be written is date/signatures at the bottom; original/digital signatures are required at time of application.

All names below must have an accompanying SECNAV 5512 in order to conduct proper background check. Names without a submitted SECNAV 5512 will not be processed.

This letter must be received by Pass and ID 10 business days prior to required access date (times may vary). Personnel must pick up their badges within 30 days being notified it is ready for issuance. Applications will be discarded after 30 days and a new one must be submitted.

Place of performance/location visiting must be properly annotated. Wahiawa, West Loch, JBPHH Main Base, etc., may be used if justification block below documents the need for base wide access.

Visitor Pass expiration date must be entered. Depending on request, expiration date WILL NOT exceed one year.

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

Approved requests will be e-mailed to the requester's and/or sponsor's e-mail address unless otherwise specified on the form.

See reverse for Privacy Act Information.

; Last Name, First Name, MI, to match individual submitted SECNAV 5512-1.

(INSTRUCTIONS)

Select Location Below (All DBIDS Credentials requests go to Nimitz): FROM: (Sponsor/Organization & Address)

PASS EXPIRATION DATE

(must be 1 year or less)

DAYS/HOURS

WORKED/VISITING

(Example: Daily/All Hours/Mon-Sat/ 0630-2000, etc)(Provide actual hours required to be on base)

LOCATION OF VISIT

(Example: Housing, Ford Island, NCTAMS, Makalapa, Pier, JBPHH, Hickam) (PaperPass 30 days or Less/DBIDS Credential 31-365 Days)

Provide detailed information):JUSTIFICATION (

VISITOR LISTING (Names Must Match Individual SECNAV 5512-1 Form Submitted)

Last Name First Name MI

Printed Name:

Organization/Number:

Visits More Than 30 Days

Signature/ Date:

COMMAND ENDORSEMENT:

(required for special, spouse, and houseguest pass requests greater than 30 days)

HOUSING ENDORSEMENT:

(Required for guest visits greater than 30 days)

Printed Name:

Housing Office/Number: Only for Houesguests

Signature/ Date:

REQUESTER SIGNATURE:

(May be Sponsor)

Date:

REQUESTER NAME:

Ex. Site Manager, Contractor, etc.

Phone & E-mail

Sign Sponsor’s Name: Date: (Day you originally signed form)

Print Sponsor’s Name:

(MILITARY SPONSOR/CONTRACT ADMINISTRATOR AND UNIT/WORK CENTER) Phone & E-mail:

PASS TYPE

(Specify pass type below)

Last Name First Name MI

JBPHH Form 0-180A 10 August 2017 https://cnic.navy.mil/regions/cnrh/installations/jb_pearl_harbor_hickam/om/pass_and_id.html

PRIVACY ACT INFORMATION

THIS FORM IS NOT INTENDED TO COLLECT IDENTIFYING INFORMATION FOR THOSE NON-AFFILIATED PERSONNEL REQUESTING TO GAIN ACCESS TO THE INSTALLATION. ALL PERSONALLY IDENTIFIABLE INFORMATION (PII) FOR BACKGROUND PURPOSES MUST BE COLLECTED AND SUBMITTED ON THE SECNAV 5512-1, DEPARTMENT OF THE NAVY LOCAL POPULATION ID CARD/BASE ACCESS PASS AND REGISTRATION FORM. THIS FORM WILL NOT BE ACCEPTED IF PERSONALLY IDENTIFIABLE INFORMATION IS FILLED IN.

DATE RECEIVED:________________________

RECEIVED BY (Print/Sign):__________________________________________________________

VISITOR LISTING (continued) Last Name First Name MI

Sign Sponsor’s Name: Date: (Day you originally signed form)

Print Sponsor’s Name:

(MILITARY SPONSOR/CONTRACT ADMINISTRATOR AND

UNIT/WORK CENTER)

Tenant Sponsor

Phone/ E-mail:

JBPHH Form 0-180A 10 August 2017 Page 2 (Use this page for continuation)

Last Name First Name MI