Application_for_Access_CBC_FILLABLE.pdf

APPLICATION FOR ACTIVITY ACCESS

AUTHORITY: Privacy Act of 1974(5 USC Section 552(A)(7))41 USC Section 423, C5 CFR Section 2635.602, AR 340-21, Title 10 and 37 USC.

PRINCIPLE PURPOSE(S): To enable military security and/or law enforcement personnel to conduct Citizenship and Criminal Background investigations for civilians requesting access to DoD Facilities.

ROUTINE USE(S): To authorize access to DoD Facilities. Information may be reported to federal, state, and local enforcement agencies with jurisdictional interest.

DISCLOSURE: Voluntary. Failure to provide requested information will result in denial of access to DoD Facilities.

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NAME (Last) NAME (First) NAME (Middle) Gender

M F

Race

Social Security Number Driver License Number Driver License State of Issue Phone (including Area Code)

Address/City/State/ZIP

Date of Birth Place of Birth (City) Place of Birth (State) Country of Birth

Hair Color Eye Color Height Weight Country of Citizenship

I understand that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. Have you ever been convicted of a felony? Yes No

If Yes, How many years since conviction? ________ Years I attest, under penalty of perjury, that I am (check one of the following: ***

A citizen of the United States A Lawful Permanent Resident ----------------------------- Alien Registration Number – A ________________ ______ _______ _____ An Alien with Employment Authorization Document (EAD) ---------------------------------------------

Employment Authorization Document Number ________ ________________________ __________

*** All non-citizens must provide an Alien registration Number or Employment Authorization Document (EAD) Number and original cards with application. Access to activity will not be authorized without this information.

Vehicle Information Vehicle Make Vehicle Model Vehicle Color License Plate # State of Issuance

Insurance Company Name Insurance Policy Number Insurance Expires

Reason for Access Reason for Access?

(Check one of the following) Delivery Contractor

Vendor Other:__________________________

Company/Contractor Name: Company/Contractor Phone # Destination/Area of worksite on activity:

How long will you need Access?

(Check one of the following)

1 Day 3-6 Months

1 Week 6-12 Months

1 Month Other: _____________________________

Point of Contact (POC) Name: POC’s Command: POC’s Phone: Pass Request

Start Date End Date

Consent to Criminal History I hereby acknowledge understanding that with the voluntary completion of this application, I am requesting access to a Department of defense (DoD) facility. I hereby authorize Navy Security Force personnel to receive any citizenship and criminal history record information pertaining to me, which may be in the files of any federal, state, or local law enforcement agencies.

I agree to return the badge to the Security Officer upon termination of employment, completion of business transactions or other reason that may cancel or alter my privilege for entry to the Station. I hereby agree to and certify that the above information and statements are true. I further agree to abide by all rules and regulations of this activity and subject myself and/or vehicle to search or detention for protection of information or property of the US Government.

Signature:__________________________________________ Date:_____________

Application Processing (For Navy Security Force Personnel Only) Pass & ID Rep Name: ID verified:

Yes No ID Number: Photo Copy Retained

Yes No

Day Walking Pass Day Vehicle Pass

30 Day Vehicle Pass 6 Month Vehicle Pass

CBC Photo Badge Other____________________ Contractor Vendor Exception

App ND Renew _____/_____ Other:___________________ NG Activity Pass Information CNSRE 5200.1 Form 1 CBC Gulfport Overprint

Activity Pass Number Issue Date Expiration Date