N6274219R1309_N6274219R1309_SV_Form.pdf

Foreign National Access Request Form Ver 2.5

PRIVACY ACT STATEMENT: AUTHORITY: Title 5 USC Section 301, Departmental Regulation Principle Purpose: To implement AFI 31-201, Installation Security and 31-218, Air Force Motor Vehicle Traffic Supervision. 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 SSN 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.

Visitor’s Escort (If Escort is sponsored, complete Primary Sponsor block)

Escort’s Sponsor Info (if required):

(AD, Guard, Res, Civ)

First Name

Middle Name:

Last Name:

Date of Birth: RANK

DD / MMM / YYYY

RANK

DD / MMM / YYYY

Contact Phone Number:

SSN:

Organization:

Home Address:

Street

____________________________, Guam ________________ City ZIP

Street

______________________________, Guam _________________ City ZIP

Visitor 1 Visitor 2 Visitor 3 First Name:

Middle Name:

Last Name:

Date of Birth: _______/____________/______

DD / MMM / YYYY

DD / MMM / YYYY

DD / MMM / YYYY

Country of Citizenship:

Identification Type [ ] Passport [ ] U.S. Visa [ ] Resident Card [ ] Other _________________________

[ ] Passport [ ] U.S. Visa [ ] Resident Card [ ] Other _________________________

[ ] Passport [ ] U.S. Visa [ ] Resident Card [ ] Other _________________________

Occupation:

Relationship to Escort:

How long is your stay on Guam?

From _______/____________/_20_____

DD / MMM / YYYY

To: _______/____________/_20_____

DD / MMM / YYYY

Other: _______________________________

From _______/____________/_20_____

DD / MMM / YYYY

To: _______/____________/_20_____

DD / MMM / YYYY

Other: _______________________________

From _______/____________/_20_____

DD / MMM / YYYY

To: _______/____________/_20_____

DD / MMM / YYYY

Other: _______________________________

Purpose of visit to Andersen?

Address while on Guam: _________________________________

Street

__________________, Guam _________ City ZIP

Street

__________________, Guam _________ City ZIP

Street

__________________, Guam _________ City ZIP