N6274218R1301_MCBHVehRegForm-Jun2016.pdf

MARINE CORPS BASE HAWAII VEHICLE REGISTRATION

PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. 552a; SECNAVINST 5211.5E; and MCO 5110.1D PRINCIPAL PURPOSE: To record data for all vehicles to be registered aboard Marine Corps Base Hawaii and issued a vehicle pass.

ROUTINE USES: The information provided on this form will be used complete the vehicle registration process upon issuance of a vehicle pass. This information is entered into the Consolidated Law Enforcement Operations Center database (CLEOC) , the Marine Corps’ designated repository for crime reporting and registration information as required to track vehicles registered aboard Department of the Navy installations. Information may be disclosed to local, county, state, and federal law enforcement or investigatory authorities in the act of conducting an official investigation. Information gathered from this form may be used in other related criminal and/or civil proceedings as required by law.

DISCLOSURE IS VOLUNTARY: SSN is used to positively identify the individual applying for access to a federal installation and as a conduit to check past criminal records. Disclosure is voluntary, however failure to provide the requested information may preclude the vehicle from being registered or permitted to access MCBH.

SECTIONS OR BLOCKS THAT DO NOT APPLY SHOULD BE LEFT BLANK

SECTION I. OWNER / DRIVER INFORMATION

LAST NAME (Include Jr./Sr./II/III/etc.)

FIRST

MIDDLE

SSN/ALIEN REG. #:

GRADE/RANK

DRIVERS LICENSE # STATE HT WT HAIR EYES

BRANCH OF SERVICE:

ARMY NAVY AIR FORCE

MARINE CORPS COAST GUARD OTHER:__________

STATUS:

REG. (ACTIVE) RESERVE RETIRED NATIONAL GUARD

FAM, MEM, CIVILIAN EMP. CIVILIAN (NO GOV. AFF.) OTHER:_______________

UNIT/ORGANIZATION (INCLUDE DEPARTMENT/COMMAND/DIVISION/UNIT, ETC.) TELEPHONE DATE OF BIRTH

DIC REQUIRED

YES / NO

HOME ADDRESS

CITY

STATE

ZIP CODE

SECTION II. SPONSOR (Use when regisitered by a person other than the Active Duty member / Sponsor may be a family member, unit, or MCCS Activity)

NAME / UNIT / ORGANIZATION LOCATION / DESTINATION POC NUMBER

SECTION III. VEHICLE INFORMATION

MAKE MODEL

COLOR

YEAR VIN

STYLE

Motorcycle Van Sedan (2DR/4DR) R/V / Camper Boat Pickup Tractor Trailer Other: ________________

REGISTRATION EXP: _____________

LICENSE PLATE # INSURANCE COMPANY POLICY # EXP:

STATE ISSUED SAFETY INSPECTION EXP:

SECTION IV. " MOVING VIOLATION HISTORY WITHIN LAST 3 YEARS (DO NOT INCLUDE PARKING VIOLATIONS / Use back for additional space if needed)

No. DATE OFFENSE DESCRIPTION FINES / FEES / PENALTIES

MILITARY INSTALLATION

OR STATE

WHERE OCCURRED

1.

2.

3.

4.

As a condition of registering and operating my motor vehicle aboard Marine Corps Base Hawaii (MCBH) I agree that: Persons accepting installation driving privileges shall be deemed to have given their consent to evidential tests for alcohol or other drug content of their blood, breath and/or urine if lawfully stopped, apprehended, or ced for any offense allegedly committed while driving or in physical control of a motor vehicle on the installation while under the influence of intoxicants.

I am aware that MCO 5110.1D and MCBH traffic code provide for the removal and temporary impoundment of privately owned motor vehicles. Any privately owned motor vehicle of which I am vested with legal possession of on MCBH that is either parked illegally for unreasonable periods, interfering with military operations, creating a safety hazard, disabled by incident, left unattended in a restricted or controlled area, or abandoned:

a. I unconditionally donate to the U.S. government all rights, title, and interests that I may posses in said vehicle.

b. I release the U.S. government from all liability for the safeguarding of said vehicle.

c. I expressly authorize the U.S. government to dispose of said vehicle in any matter it deems fit.

d. I expressly release the U.S. government, its officers and agents from any liability, charges, and claims that I may have regarding the sale or other disposition of said vehicle.

I affirm that the information provided above is accurate to the best of my knowledge. I understand that I may not register, or operate my vehicle aboard MCBH while my state or base operating privileges have been suspended or revoked. I must deregister my vehicle and relinquish possession of my vehicle pass to the Pass and Registration Office located at building 1095, Kaneohe Bay or building 601, Camp Smith.

SECTION V. OWNER / DRIVER ACKNOWLEDGMENT AND CONSENT

LAST NAME

MI

SIGNATURE

SECTION VI. COMMAND APPROVING OFFICIAL (Personnel must be an E-8 or above, designated in writing by the Commanding Officer)

LAST NAME

MI

SIGNATURE

SECTION VII. ADMINISTRATIVE DISPOSITION (PMO USE ONLY)

DATE ISSUED: EXPIRATION DATE: PMO ISSUING OFFICIAL:

SIGNATURE

robert.schwindboone Typewritten Text FOR OFFICIAL USE ONLY (when filled in) robert.schwindboone Typewritten Text FOR OFFICIAL USE ONLY (when filled in) robert.schwindboone Typewritten Text MCBH MPD 5000/9 (Rev. 6-16) PREVIOUS EDITIONS ARE OBSOLETE ADOBE ACROBAT PRO 9.0