S02 - Visitor_Access_Form.pdf

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ROCK ISLAND ARSENAL ACCESS CONTROL RECORD CHECK

Visitors are Welcome to RIA

SECTION I

NAME (Last, First, Middle Name)

LAST FOUR OF SOCIAL SECURITY #

E-MAIL

DATE OF BIRTH (DAY/MONTH/YEAR)

OTHER NAMES USED (No nicknames)

HOME ADDRESS/NUMBER AND STREET:

CITY

STATE

ZIP CODE

PURPOSE OF VISIT

OFFICIAL BUSINESS:

RECREATIONAL VISIT:

GOVERNMENT POINT OF CONTACT (For Official Business Visits Only)

LENGTH OF VISIT

TO:

DATE:

FREQUENCY OF VISIT:

ONE TIME

DAILY

WEEKLY

MONTHLY

FIRST ARMY

ARDEC

ARMY SUSTAINMENT COMMAND

CHRA/CPAC

COMMISSARY/PX

CONTRACTING

CREDIT UNION

JOINT MUNITIONS COMMAND

JMTC

FISHING

GOLF

DINING CLUB HOUSE

GYM

MWR EVENT

MUSEUM

LOCK & DAM VISITOR CENTER

HISTORIC SITES

OTHER

PURPOSE OF VISIT:

NAME:

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

ECBC

GARRISON

RESERVE CENTER

CEMETERY

OTHER

LOCATION:

OTHER:

RIA FORM 190-1, JANUARY 2017

RACE

SEX

F Y N

U.S. CITIZEN

M

PLACE OF BIRTH:

PHONE:

SECTION II

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

PRIVACY ACT STATEMENT

I Authorize a representative of the Rock Island Arsenal, Directorate of Emergency Services to conduct my background check, to obtain any information relating to my criminal history record. I authorize the Rock Island Arsenal Police Department, 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.

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

a. SIGNATURE OF APPLICANT

b. DATE

16. RETURN THIS FORM BY EMAIL, FAX OR MAIL TO: Directorate of Emergency Services Fax: 309-782-5029 Visitor Control Center Phone: 309-782-0551 ATTN: Building # 23 (IMRI-ESS-A) Email: usarmy.ria.imcom.mbx.usag-access-request@mail.mil Rock Island Arsenal Rock Island, IL 61299 You may also bring this completed form in person with you to the Visitor Control Center.

***** APPLICANT DO NOT WRITE BELOW THIS LINE *****

FITNESS DETERMINATION OFFICER OFFICIAL USE ONLY

SECTION III

REVIEWING AUTHORITY

APPROVED

DISAPPROVED

REASON DISAPPROVED

APPROVING AUTHORITY

REMARKS

DATE

RIA FORM 190-1, JANUARY 2017

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