N6274218R1301_MCBHBaseAccessRequest.pdf

PASS AND REGISTRATION OFFICE USE ONLY

RECEIVED BY

MARINE CORPS BASE HAWAII

CONTRACTOR/VENDOR/SERVICE PROVIDER BASE ACCESS REQUEST FORM

AUHORITY:5.U.S.C. 522A & SECNAVINST 5211.5E

PRINCIPAL USE: To record data for all nongovernment personnel requesting access to Marine Corps Base Hawaii.

ROUTINE USES: The social security number will be used to complete the Marine Corps Base Hawaii access application process. This information is entered into the National Crime Information Center (NCIC), the Hawaii Criminal Justice Information Center (HCJIS) and Consolidated Law Enforcement Operations Center (CLEOC), to conduct a criminal history check on the person requesting access to Marine Corps Base Hawaii.

DISCLOSURE: The social security number is used to positively identify the applicant requesting access to Marine Corps Base Hawaii, and is a conduit to check criminal records. Disclosure is voluntary; however, failure to provide the requested information may deny you to access to Marine Corps Base Hawaii.

DATE OF REQUEST

LOCATION

NAME (Last, First, Middle)

FULL SSN

XXX-XX-XXXX

TYPE OF PASS REQUESTED

Day Pass 30 Day Pass 6 Month Pass Year Pass

POC PHONE NUMBERREQUESTING OFFICE (I.E. FEAD, ROICC, FACILITIES) POC

CONTRACT NUMBER START DATE OF VISIT END DATE OF VISIT

PURPOSE OF VISIT

CONTRACTOR/VENDOR/SERVICE PROVIDER INFORMATION

RAPID GATE

BADGE NUMBER

DATE RECEIVED

Submit this form to the Pass and Registration Office, building 1095 1st floor, MCB Hawaii, at least five (5) business days prior to the visitation start date. Use continuation sheet if necessary.

Pass and Registration phone number 257-2047/0183.

NOTE: If request is not made at least five (5) business days in advance, an authorized sponsor will need to call the Passhouse at 257-2047 from an authorized phone number to sponsor the individual(s) on the date of the visit until the pass(es) have been processed.

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

DATE:______________________

DATE:______________________

DATE:______________________

EBW: YES

NCIC:

CLEOC:

SP:

DATE:______________________

YES

YES

YES

NO COMPLETED BY _________________

NO COMPLETED BY _________________

NO COMPLETED BY _________________

NO COMPLETED BY _________________

COMPANY

RAPID GATE

ENROLLED ON

MCBH