1_INSTALLATION_ACCESS_REQ_FORM.pdf

INSTALLATION ACCESS REQUEST FORM

*** Submit this request to VCC at least 30 DAYS prior to the guest's anticipated arrival for Third Country Nationals and 10 business days prior to the expiration of the House Guest Pass for Extension Requests. ***

Section 1: Visitor Information Last Name First Name Middle Name

Date of Birth Nationality/Citizenship ID Type * (See Reverse) ID Number * (See Reverse)

Height Weight Color of Eyes Color of Hair Gender

Male Female

Guest’s Home Address Purpose of Vist

Section 2: Dates Requested

From Year Month Day

To Year Month Day

2 0 2 0 Section 3: Time

From (Earliest Time) To (Latest Time)

Remarks:

Section 4: Sponsor Information Last Name First Name Middle Name Rate/Rank

Command Name Work Phone Number Home/Cell Phone Number

E-mail Address:

Reason for Request for Extension

Lodging for Guest while visiting

Section 5: VCC (Extension Only) Total number of Days

a. I understand I am responsible for the actions of the above listed person while on the installation and for the return of the pass upon its expiration.

b. I understand that all passes already received are included in the 60 days per 365 day period.

c. I will constantly escort my guest while on the installation, if required.

d. I understand that failure to do so will result in suspension of my and my guest's privileges.

Sponsor’s Signature

Endorsement/Final Approval Approved Disapproved Signature

Sponsor’s Command

USNH/Stork’s Nest (if applicable for Overnight Guest Only)

Housing Director (for Overnight Guest Only)

NCIS FEFO

(for 3rd Country National Only)

Installation Security Officer

Commander, FLEACT Yokosuka (if applicable)

Section 6: Pass Type

Check One: Official Unofficial

Check One: Escort Only Unescorted

Overnight Unescorted Overnight Escorted Third Country National Pass

DBIDS Category:

Figure 1.1 Page 1 of 2

FOR OFFICIAL USE ONLY – PRIVACY SENSITIVE

INSTALLATION ACCESS REQUEST FORM

*** Submit this request to VCC at least 30 DAYS prior to the guest's anticipated arrival for Third Country Nationals and 10 business days prior to the expiration of the House Guest Pass for Extension Requests. ***

PRIVACY ACT STATEMENT:

AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; OPNAVINST 5530.14E, Navy Physical Security; Marine Corps Order 5530.14A,Marine

Corps Physical Security Program Manual; and E.O. 9397 (SSN), as amended, SORN NM05512-2.

PURPOSE(S): To control physical access to Department of Defense (DoD), Department of the Navy (DON) or U.S. Marine Corps Installations/Units controlled information, installations, facilities, or areas over which DoD, DON, or U.S. Marine Corps has security responsibilities by identifying or verifying an individual through the use of biometric databases and associated data processing/information services for designated populations for purposes of protecting U.S./Coalition/allied government/national security areas of responsibility and information; to issue badges, replace lost badges, and retrieve passes upon separation; to maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/exit times of personnel.

ROUTINE USE(S): To designated visitors, contractors, Federal agencies, and foreign governments for the purpose of granting Navy officials access to their facility.

DISCLOSURE: Providing registration information is voluntary. Failure to provide requested information may result in denial of access to benefits, privileges, and DoD installations, facilities and buildings.

By signing below, I understand my information will be safeguarded in accordance with the requirements of 5 U.S.C. 552a, DoDD 5200.27, DoDD 5400.11, DoD 5400.11-R, DoDI 5505.17, DoDI 5400.16, and Volume 4 of DoD Manual (DoDM) 5200.01

I also understand that I may choose not to write my identification number on the form, but must provide the information to the Visitor Control Center for registration into the

Defense Biometrics Identification System.

Visitor Signature/Date

Figure 1.1 Page 2 of 2

FOR OFFICIAL USE ONLY – PRIVACY SENSITIVE