POM_FORM_7_Application_for_Installation_Access Template.pdf

SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.

SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.

APPLICATION FOR INSTALLATION ACCESS

(FOR U.S. CITIZEN APPLICANTS ONLY)

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY: Public Law 110-181, The 2008 National Defense Authorization Act, Section 109.

PRINCIPAL PURPOSE: Provide necessary information to determine if applicant meets the installation access requirements in accordance with the U.S. Army Garrison, Presidio of Monterey Command Policy # 17, Installation Access Procedures for Visitors. Use of Date of Birth, Driver's License number and Social Security Number (SSN) are necessary for positive identification of the applicant in the Department of Justice database. Use of SSN includes the full 9-digit or the last 4-digit only.

ROUTINE USE: National Crime Information Center Interstate Identification Index (NCIC III) criminal history check using the Department of Defense database.

DISCLOSURE IS VOLUNTARY: Disclosure of SSN and other information is voluntary. However, applicant's failure to provide full name, Date of Birth, Driver's License number, and SSN will result in a delay or denial of installation access. Sponsor's failure to provide Date of Birth and SSN when requesting a Defense Biometric Identification Data System (DBIDS) card for an applicant will result in denial of DBIDS card issue.

1. LAST NAME, FIRST NAME, MIDDLE INITIAL

DRIVER'S LICENSE NUMBER ISSUING STATE

SECTION I. SPONSOR'S INFORMATION (To be completed by the sponsor requesting personnel listed below for inclusion to the Installation Access Roster to permit entry to the U.S. Army, Presidio of Monterey, California. Sponsor will be responsible for all actions of their guests while on the installation).

a. SPONSOR'S LAST NAME, FIRST NAME, MIDDLE INITIAL

POM Form 7, October 2015 PREVIOUS EDITION IS OBSOLETE Page 1 of 2

g. PURPOSE OF VISIT (Please provide details in the space provided below)

e. CONTRACT EXPIRATION DATE (CONTRACTORS ONLY)

c. SPONSOR'S ORGANIZATION

TO

SIGNATURE

ACCESS ROSTER

DBIDS CARD

RENEWAL INITIAL REQUEST

DATE

TO

MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY

d. DATE OF BIRTH (MM/DD/YYYY)

Enter Sponsor's Full SSN. This is required to verify enrollment in the Defense Enrollment Eligibility Reporting System (DEERS)

FROM FROM

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF BIRTH (MM/DD/YYYY)

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

Mission Requirement Other

f. TYPE OF REQUEST (Select one only)

SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.

3. LAST NAME, FIRST NAME, MIDDLE INITIAL

DRIVER'S LICENSE NUMBER ISSUING STATE

TO TO

MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY

FROM FROM

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF BIRTH (MM/DD/YYYY)

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

2. LAST NAME, FIRST NAME, MIDDLE INITIAL

DRIVER'S LICENSE NUMBER ISSUING STATE

TO TO

MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY

FROM FROM

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF BIRTH (MM/DD/YYYY)

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

Information collected in this form is FOR OFFICIAL USE ONLY. Sponsors will collect the required applicant information individually and not provide applicant access to each other's protected personal information. Once completed, if submitted via email using government computer, this application must be sent encrypted to the shared access email address: usarmy.pom.106-sig-bde.list.pres-installationaccess@mail.mil. If using personal email, ensure that the security of your email system is adequate for sending sensitive information before choosing to transmit as this contains Personally Identifiable Information.

SECTION II. INFORMATION ON U.S. CITIZEN APPLICANT(S)

b. SPONSOR'S WORK PHONE (Area Code and Number)

SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.

APPLICATION FOR INSTALLATION ACCESS

(FOR U.S. CITIZEN APPLICANTS ONLY)

FOR APPROVING AUTHORITY USE ONLY

FOR LAW ENFORCEMENT USE ONLY

DATEPRINTED NAME SIGNATURE

POM Form 7, October 2015 PREVIOUS EDITION IS OBSOLETE Page 2 of 2

SECTION II. INFORMATION ON U.S. CITIZEN APPLICANT(S) (Continuation page)

APPROVED

DISAPPROVED

DISQUALIFYING FACTORS

YES NO

DATE NCIC III CONDUCTED

4. LAST NAME, FIRST NAME, MIDDLE INITIAL

DRIVER'S LICENSE NUMBER ISSUING STATE

TO TO

MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY

FROM FROM

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF BIRTH (MM/DD/YYYY)

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

5. LAST NAME, FIRST NAME, MIDDLE INITIAL

DRIVER'S LICENSE NUMBER ISSUING STATE

TO TO

MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY

FROM FROM

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF BIRTH (MM/DD/YYYY)

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

6. LAST NAME, FIRST NAME, MIDDLE INITIAL

DRIVER'S LICENSE NUMBER ISSUING STATE

TO TO

MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY

FROM FROM

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF BIRTH (MM/DD/YYYY)

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

7. LAST NAME, FIRST NAME, MIDDLE INITIAL

DRIVER'S LICENSE NUMBER ISSUING STATE

TO TO

MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY

FROM FROM

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF BIRTH (MM/DD/YYYY)

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

8. LAST NAME, FIRST NAME, MIDDLE INITIAL

DRIVER'S LICENSE NUMBER ISSUING STATE

TO TO

MONDAY SATURDAY SUNDAY FRIDAY THURSDAY WEDNESDAYTUESDAY

FROM FROM

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF BIRTH (MM/DD/YYYY)

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.

SSN (Last 4- digit only). Verification required in California Law Enforcement Telecommunication System.

APPLICATION FOR INSTALLATION ACCESS

(FOR U.S. CITIZEN APPLICANTS ONLY)

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY: Public Law 110-181, The 2008 National Defense Authorization Act, Section 109.

PRINCIPAL PURPOSE: Provide necessary information to determine if applicant meets the installation access requirements in accordance with the U.S. Army Garrison, Presidio of Monterey Command Policy # 17, Installation Access Procedures for Visitors. Use of Date of Birth, Driver's License number and Social Security Number (SSN) are necessary for positive identification of the applicant in the Department of Justice database. Use of SSN includes the full 9-digit or the last 4-digit only.

ROUTINE USE: National Crime Information Center Interstate Identification Index (NCIC III) criminal history check using the Department of Defense database.

DISCLOSURE IS VOLUNTARY: Disclosure of SSN and other information is voluntary. However, applicant's failure to provide full name, Date of Birth, Driver's License number, and SSN will result in a delay or denial of installation access. Sponsor's failure to provide Date of Birth and SSN when requesting a Defense Biometric Identification Data System (DBIDS) card for an applicant will result in denial of DBIDS card issue.

SECTION I. SPONSOR'S INFORMATION (To be completed by the sponsor requesting personnel listed below for inclusion to the Installation Access Roster to permit entry to the U.S. Army, Presidio of Monterey, California. Sponsor will be responsible for all actions of their guests while on the installation).

POM Form 7, October 2015 PREVIOUS EDITION IS OBSOLETE Page 1 of 2

g. PURPOSE OF VISIT (Please provide details in the space provided below)

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

f. TYPE OF REQUEST (Select one only)

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

Information collected in this form is FOR OFFICIAL USE ONLY. Sponsors will collect the required applicant information individually and not provide applicant access to each other's protected personal information. Once completed, if submitted via email using government computer, this application must be sent encrypted to the shared access email address: usarmy.pom.106-sig-bde.list.pres-installationaccess@mail.mil. If using personal email, ensure that the security of your email system is adequate for sending sensitive information before choosing to transmit as this contains Personally Identifiable Information.

SECTION II. INFORMATION ON U.S. CITIZEN APPLICANT(S)

APPLICATION FOR INSTALLATION ACCESS

(FOR U.S. CITIZEN APPLICANTS ONLY)

FOR APPROVING AUTHORITY USE ONLY

FOR LAW ENFORCEMENT USE ONLY

POM Form 7, October 2015 PREVIOUS EDITION IS OBSOLETE Page 2 of 2 SECTION II. INFORMATION ON U.S. CITIZEN APPLICANT(S) (Continuation page)

DISQUALIFYING FACTORS

DATE NCIC III CONDUCTED

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

DAYS REQUESTED ACCESS

TIME OF REQUESTED ACCESS

DATE OF REQUESTED ACCESS (MM/DD/YYYY)

8.0.1291.1.339988.308172