Visitor Access Form.pdf

ROCK ISLAND ARSENAL ACCESS REQUEST FORM

Visitors are Welcome to RIA!

SECTION I - PERSONAL INFORMATION

NAME (Last, First, Middle Name)

LAST FOUR OF SOCIAL

SECURITY #

DATE OF BIRTH

(Month/Day/Year)

HOME ADDRESS/NUMBER AND STREET: CITY STATE ZIP CODE

SECTION II - PURPOSE OF VISIT

OFFICIAL/COMMERICAL BUSINESS: RECREATIONAL VISIT

GOVERNMENT CONTACT NAME:

FIRST ARMY

ASC

COMMISSARY/PX CONTRACTOR

CREDIT UNION

JMC

JMTC

FISHING

QUARTERS 1

COL DAVENPORT

HOUSE

ARSENAL ATTIC MWR EVENT

MUSEUM

LOCK & DAM

VISITOR CENTER

RECREATIONAL

OTHER:

PHONE:

Purpose: The United States Army requires a criminal records check be conducted on all visitors not affiliated with the Department of Defense or US Government.

ARMY CORPS OF ENGINEERS

GYM

RESERVE CENTER

CEMETERY

RIA FORM 190-1, June 2022

RACE

SEX

F

Y N

U.S. CITIZEN

M

PLACE OF BIRTH (State):

PHONE:

FAMILY HOUSING

NEW HIRE

RIDESHARE

(IE: UBER, TAXI)

SECTION III (For Official/Commercial Business Only)

SECTION IV PRIVACY ACT STATEMENT

I HEREBY CONSENT TO THE RELEASE OF MY CRIMINAL HISTORY RECORDS.

I Authorize a representative of the Rock Island Arsenal, Division of Emergency Services (DES) to conduct my background check, to obtain any information relating to my criminal history record. I authorize the Rock Island Arsenal DES, conducting my investigation to disclose the record of my background investigation to the official responsible for making a determination of suitability or eligibility for access to Rock Island Arsenal. I understand that the information released by records custodians and sources of information is for OFFICIAL USE ONLY by the Rock Island Arsenal for the purposes stated and that it may be re-disclosed by the government only as authorized by law. I further understand that with the signing of this form I authorize additional background checks as may be needed by representatives of the Rock Island Arsenal for continuing access to the installation.

My information on this form is true, complete, and correct to the best of my knowledge.

SIGNATURE OF APPLICANT DATE:

DELIVERY/PICK-UP

VISITOR COMPANY NAME:

PHONE:

This form must be completed and brought with you in person or it can be submitted to the Visitor Welcome Center via e-mail: usarmy.RIA.imcom.mbx.usag-access-request@army.mil from a (.mil) address.

Visitor Welcome Center FAX: 309-782-5029 23 Prospect Dr. Phone: 309-782-1337 Moline, IL 61265 Email: usarmy.RIA.imcom.mbx.usag-access-request@army.mil (Outside Moline Gate) Rock Island Arsenal

Bring this form in person with you.

Tracking #

VWC COMPLETE

OUTDOOR RECGOLF

SECTION V (To be completed by DES Personnel)

APPEAL

PACKET GIVEN

REASON FOR:

NLETS OVERRIDE,

APPEAL PACKET NOT GIVEN

Y N

DASG Print Last Name/Badge #

ACCEPTABLE FORMS OF INDENTIFICATION

State Issued Driver's License

State issued Identification Card United States Passport

United States Passport Card Veteran Health Identification Card (VHIC) W/Service Connected

1. If operating a vehicle you must have a valid driver's license, current registration, and proof of valid insurance while on Rock Island Arsenal.

2. All personnel requesting access will be subject to Vetting, a records check through the National Crime Information Center (NCIC) Interstate Identification Index (III) is the minimum baseline background check for entrance onto Army installations for non-CAC holders to include entrance of Visitors and Contractors.

3. Persons who do not pass the security vetting will be denied access and may request the process for submitting a denial waiver.

The denial wavier process is non-waiverable. The appeal process can take an extended period of time.

4. Visitor Welcome Center staff may contact their Government POC to verify that access is still required.

5. All information on the access request form must be completed. The completed form and a verification document listed above are to be presented to staff.

6. Any conduct which is detrimental to the maintenance of good order and discipline on the Rock Island Arsenal may result in confiscation of the visitor pass/badge, immediate removal from the installation, and the possibility of being barred from the Installation.

7. The Government POC/sponsor has overall responsibility for the conduct of the pass holder at all times while they are on the Installation. While this does not include punitive liability, the Agent may be required to brief senior installation leaders regarding acts of employee misconduct.

8. Pass holders will confine themselves only to those Areas and Hours related to issuance.

9. Pass holders will not enter any marked, restricted and/or controlled areas unless specifically authorized to. Be prepared to identify yourself and the purpose of your presence on to police or security personnel at all times.

10. All persons, their possessions, and vehicles are liable to search upon entry into and exit from Rock Island Arsenal and while within the boundaries of the military reservation.

11. Firearms, concealed weapons, and other personal weapons are prohibited.

NOTE:

RIA FORM 190-1, June 2022

ACCESS

DENIED

ACCESS

GRANTED

Date

Length

NCIC/NLETS

HIT

Time Out

Time In

VWC

Moline Gate

VHIC

CONTRACTOR

U.S. VISITOR

FOREIGN VISITOR

FAMILY (Dependent)

VISITOR TYPE LOCATION

DOD-CAC

NCIC User/Dispatcher

ROCK ISLAND ARSENAL ACCESS REQUEST FORM

Visitors are Welcome to RIA!

SECTION I - PERSONAL INFORMATION

NAME (Last, First, Middle Name)

LAST FOUR OF SOCIAL SECURITY #

DATE OF BIRTH

(Month/Day/Year)

HOME ADDRESS/NUMBER AND STREET:

CITY

STATE

ZIP CODE

SECTION II - PURPOSE OF VISIT

OFFICIAL/COMMERICAL BUSINESS:

RECREATIONAL VISIT

GOVERNMENT CONTACT NAME:

FIRST ARMY

ASC

COMMISSARY/PX

CONTRACTOR

CREDIT UNION

JMC

JMTC

FISHING

QUARTERS 1

COL DAVENPORT HOUSE

ARSENAL ATTIC

MWR EVENT

MUSEUM

LOCK & DAM VISITOR CENTER

RECREATIONAL

OTHER:

PHONE:

Purpose: The United States Army requires a criminal records check be conducted on all visitors not affiliated with the Department of Defense or US Government.

ARMY CORPS OF ENGINEERS

GYM

RESERVE CENTER

CEMETERY

RIA FORM 190-1, June 2022

RACE

SEX

F Y N

U.S. CITIZEN

M PLACE OF BIRTH (State):

PHONE:

FAMILY HOUSING

NEW HIRE

RIDESHARE (IE: UBER, TAXI)

SECTION III (For Official/Commercial Business Only)

SECTION IV PRIVACY ACT STATEMENT

I HEREBY CONSENT TO THE RELEASE OF MY CRIMINAL HISTORY RECORDS.

I Authorize a representative of the Rock Island Arsenal, Division of Emergency Services (DES) to conduct my background check, to obtain any information relating to my criminal history record. I authorize the Rock Island Arsenal DES, conducting my investigation to disclose the record of my background investigation to the official responsible for making a determination of suitability or eligibility for access to Rock Island Arsenal. I understand that the information released by records custodians and sources of information is for OFFICIAL USE ONLY by the Rock Island Arsenal for the purposes stated and that it may be re-disclosed by the government only as authorized by law. I further understand that with the signing of this form I authorize additional background checks as may be needed by representatives of the Rock Island Arsenal for continuing access to the installation.

My information on this form is true, complete, and correct to the best of my knowledge.

SIGNATURE OF APPLICANT

DATE:

DELIVERY/PICK-UP

VISITOR COMPANY NAME:

PHONE:

This form must be completed and brought with you in person or it can be submitted to the Visitor Welcome Center via e-mail: usarmy.RIA.imcom.mbx.usag-access-request@army.mil from a (.mil) address.

Visitor Welcome Center FAX: 309-782-5029 23 Prospect Dr. Phone: 309-782-1337 Moline, IL 61265 Email: usarmy.RIA.imcom.mbx.usag-access-request@army.mil (Outside Moline Gate) Rock Island Arsenal Bring this form in person with you.

Tracking #

VWC COMPLETE

OUTDOOR REC

GOLF

SECTION V (To be completed by DES Personnel)

APPEAL PACKET GIVEN

REASON FOR:

NLETS OVERRIDE,

APPEAL PACKET NOT GIVEN

Y N

DASG Print Last Name/Badge #

ACCEPTABLE FORMS OF INDENTIFICATION

State Issued Driver's License State issued Identification Card United States Passport United States Passport Card Veteran Health Identification Card (VHIC) W/Service Connected

1. If operating a vehicle you must have a valid driver's license, current registration, and proof of valid insurance while on Rock Island Arsenal.

2. All personnel requesting access will be subject to Vetting, a records check through the National Crime Information Center (NCIC) Interstate Identification Index (III) is the minimum baseline background check for entrance onto Army installations for non-CAC holders to include entrance of Visitors and Contractors.

3. Persons who do not pass the security vetting will be denied access and may request the process for submitting a denial waiver. The denial wavier process is non-waiverable. The appeal process can take an extended period of time.

4. Visitor Welcome Center staff may contact their Government POC to verify that access is still required.

5. All information on the access request form must be completed. The completed form and a verification document listed above are to be presented to staff.

6. Any conduct which is detrimental to the maintenance of good order and discipline on the Rock Island Arsenal may result in confiscation of the visitor pass/badge, immediate removal from the installation, and the possibility of being barred from the Installation.

7. The Government POC/sponsor has overall responsibility for the conduct of the pass holder at all times while they are on the Installation. While this does not include punitive liability, the Agent may be required to brief senior installation leaders regarding acts of employee misconduct.

8. Pass holders will confine themselves only to those Areas and Hours related to issuance.

9. Pass holders will not enter any marked, restricted and/or controlled areas unless specifically authorized to. Be prepared to identify yourself and the purpose of your presence on to police or security personnel at all times.

10. All persons, their possessions, and vehicles are liable to search upon entry into and exit from Rock Island Arsenal and while within the boundaries of the military reservation.

11. Firearms, concealed weapons, and other personal weapons are prohibited.

NOTE:

RIA FORM 190-1, June 2022

ACCESS DENIED

ACCESS GRANTED

Date Length

NCIC/NLETS

HIT

Time Out Time In

VWC

Moline Gate

VHIC

CONTRACTOR

U.S. VISITOR

FOREIGN VISITOR

FAMILY (Dependent)

VISITOR TYPE

LOCATION

DOD-CAC

NCIC User/Dispatcher 9.0.0.2.20120627.2.874785