N6274219R1304_Foreign_National_Access_Req.pdf

DEPARTMENT OF THE AIR FORCE

HEADQUARTERS 36TH WING (PACAF)

ANDERSEN AIR FORCE BASE GUAM

Foreign National Access Request Form Contractor Request

APPROVED BY: ___________________________ TRACKING NUMBER: _______________________ FVR NUMBER:

_________________ PROJECT COORDINATOR CONTRACTING OFFICER

First Name

Last Name:

Contact Phone Number:

Email Address:

Organization:

Visitor’s intended location on Andersen:

Visitor 1 Visitor 2 Visitor 3 Visitor 4 First Name:

Last Name:

Date of Birth:

DD / MMM / YYYY

DD / MMM / YYYY

DD / MMM / YYYY

DD / MMM / YYYY

Country of Citizenship:

Identification Type

[] Passport [] I-94 [] U.S. Visa [] Other:___________

[] Passport [] I-94 [] U.S. Visa [] Other:___________

[] Passport [] I-94 [] U.S. Visa [] Other:___________

[] Passport [] I-94 [] U.S. Visa [] Other:___________

Occupation:

Place of Employment:

Relationship to Escort:

How long is your stay on Andersen AFB?

From:________/________/________

DD MMM YYYY

To:________/_________/_________

DD MMM YYYY

From:________/________/________

DD MMM YYYY

To:________/_________/_________

DD MMM YYYY

From:________/________/________

DD MMM YYYY

To:________/_________/_________

DD MMM YYYY

From:________/________/________

DD MMM YYYY

To:________/_________/_________

DD MMM YYYY

Purpose of visit to Andersen?

Address while on Guam:

Street

_________________________,, Guam _______ City Zip

Street

_________________________,, Guam _______ City Zip

Street

_________________________,, Guam _______ City Zip

Street

_________________________,, Guam _______ City Zip

PRIVACY ACT STATEMENT: AUTHORITY: Title 5 USC Section 301, Departmental Regulation Principle Purpose: To record personal information and determine access to the installation ROUTINE PURPOSE: To request and record the issuance of a Visitor Pass when the use of another form is not authorized or specified. Failure to provide any information requested may result in non-issuance of the Visitor Pass. Disclosure of information is voluntary acceptance of these terms constitutes approval for a background check to be conducted as part of the request approval process. The information is necessary for validation of identity and determination of entry eligibility on to Andersen Air Force Base. Failure to provide this information may result in non-issuance determination by the issuing authority.

Date Approved: _________________