Attachment_5_-_ASG-KU_PMO_Form_190-16.01_(Access_Application_-_01Feb12).doc

ASG-KU ACCESS APPLICATION

Data Required by the Privacy Act of 1974 (5 USC 552a), DoD Directive 5400.11-R, 10 USC 3013, 10 USC 5013, 10 USC 8013 and Executive Order 9397

AUTHORITY: 10 U.S.C. 113, Secretary of Defense, Note (Use of Smart Card Technology in the Department of Defense); Directive-Type Memorandum (DTM) 09-012, Interim Policy Guidance for DoD Physical Access Control; 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; DoD Directive 1000.25, DoD Personnel Identity Protection (PIP) Program; DoD Instruction 5200.08, Security of DoD Installations and Resources; DoD 5200.08-R, Physical Security Program; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): The records support DoD physical security and information assurance programs, to issue individual facility/installation access credentials, and for identity verification purposes. The system also is used to record personal vehicles and property registered with the DoD and for producing facility management reports. The records may be accessed by other physical access control systems for further verification at other sites. Records may also be used for law enforcement purposes.

ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act of 1974, these records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a (b) (3) as follows: Under DoD Blanket Routine Use #1. For law enforcement purposes to …federal, state, local, or foreign (law enforcement agencies), charged with enforcing or implementing the statute, rule, regulation, or order issued pursuant thereto. The DoD 'Blanket Routine Uses' set forth at the beginning of the OSD compilation of systems of records notices apply to this system.

DISCLOSURE REQUIREMENT – THIS INFORMATION IS VOLUNTARY: Voluntary. However, failure to provide the requested information may result in denial of a DBIDS card or visitor’s pass and denial of entry to DoD installations and/or facilities.

CONDITIONS APPLICABLE ON RECEIPT: I understand that the ASG-KU Installation Access (IA) Card is valid only through the expiration date indicated. Exceptions may require additional screening, interview and background checks. It should also be known that any derogatory information returned from the applicant's background investigation or failure to comply with screening/interview requirements may reflect adversely on consideration for access and may result in barment proceedings being initiated. Its intended use and authorizations are limited to those indicated on this form and the card. I understand that the ASG-KU IA Card is US Government property, that it is not transferable, that it is not to be altered in any way, and that it must be surrendered upon request of the US Government, its designated representative, or the issuing agency. I understand that while on any ASG-KU Installation my person, possessions, vehicle and work area are subject to search at the discretion of the US Government or its designated representative. I understand that I am liable for the cost of replacement for my IA Card if lost. Any falsification on this form will result in immediate revocation of access privileges.

1. Last Name (Surname):

12. Title/Position:

13. Rank/Grade:

2. First Name (Given Name):

14. Citizenship/Nationality (If dual Citizen list both countries):

15. Race:

3. Middle Name/Suffix:

16. Address Type:

Organization Address Company Address Home Address Office Address

4. Passport Number:

Expiration Date (yyyy/mmm/dd):

17. Address (Building Name/Number, Street Name/Number, etc):

5. Foreign Identification Number:

Expiration Date (yyyy/mmm/dd):

18. City, State, Zip code:

19. Country:

First Name:

6. Date of Birth (yyyy/mmm/dd):

20. Home Phone Number:

21. Mobile Phone Number:

9. Gender:

Male Female

10. Eye Color:

11. Hair Color:

22. Work Phone Number:

23. DSN Phone Number:

SECTION II – Access Information

24. Purpose of Application

CAC TDY Escort Request New Registration Renew Registration Upgrade of Privileges Lost/Damaged Card ID Number:

25. Work Hours:

From:

From:

Sat Sun Mon Tue Wed Thu Fri

SECTION III – Company/Contract Information

28. Unit/Employer:

29. Department and Section:

30. Work Location of Employee:

31. Project Name/Task Order:

DBIDS Number:

32. Supervisor Name:

33. Supervisor Work Number:

34. US Military Contract Number:

35. Contract Expiration Date (yyyy/mmm/dd):

36. Contract Period (Base plus option years):

37. Primary Contract Company:

38. Primary Contract Company Contact Information:

39. Name of Primary Contract Company Representative:

40. Signature of Primary Contract Company Representative:

41. Subcontract #:

42. Subcontract Point of Contact (POC):

ASG-KU ACCESS APPLICATION

43. RA Last Name:

44. RA First and Middle Name:

45. RA Rank/Grade or Equivalent:

46. RA Unit/Organization:

47. RA Work Number:

48. RA Mobile Number:

49. RA E-Mail Address:

50. Signature and Date:

51. Areas Of Access

Directorate/COR/RA must initial for each camp required.

(Note: Access is based on the individual’s need as stated in their contract. It is strictly prohibited to access areas not specified in their contract.)

Camp Arifjan

Initials:________ Camp Buehring

Initials:________ SPOD – w/Enc 7 Initials:________ Khabari – w/Enc 7 Initials:________

Camp Virginia

LSA

KNB (Patriot)

Other:

Initials:________ U.S. Border Crossing – Access via Iraq/Kuwait Border

52. Personal Access in Force Protection Condition: Initials:

CHARLIE DELTA

Submit justification in Block 55 for ‘Delta’ Access

53. Vehicle Access in FP Condition: Initials:

CHARLIE DELTA NO VEHICLE

Submit justification in Block 55 for ‘Delta’ Access

54. Escort Privileges: Initials:

NO YES

Submit justification Block 55 for ‘Escort Privileges’

55. Remarks: (Specific Areas Access; Personal/Vehicle FPCON DELTA Access or Escort justification)

56. Expiration Date Recommendation: Initials:

57. Acknowledgement of ASG-KU IA Card Holder Responsibilities

As a ASG-KU IA Card holder, I acknowledge the following:

1. All persons, their personal property, US Government property, and vehicles may be searched on entry, while within the confines of, or when leaving US Forces installations. Persons attempting to gain entry, who refuse to identify themselves, provide digitized fingerprint minutia data (DFMD), hand geometry scan, or consent to search, will be denied access.

2. If I am authorized escort privileges, I understand that I am agreeing to monitor that person’s actions at all times, and I accept full responsibility for that person’s conduct while on the installation.

3. IA Cards are US Government property. Any Military Police Officer, Law Enforcement, Security Force or Access Control personnel may confiscate an IA Card that has expired, is being used fraudulently, and is being presented by a person other than the person to whom it was issued, or is obviously altered, damaged, mutilated or photocopied.

4. I must surrender my pass when

a. It is replaced (except when lost or stolen).

b. I no longer require access.

c. My sponsor or status changes.

d. I resign, am terminated, or am no longer officially sponsored.

5. If I lose my IA Card or if it is stolen, I must immediately notify either the Law Enforcement Station or Installation Access Office. Failure to do so is grounds for denying a replacement card.

6. Violations of ASG-KU security policies may be grounds for denying access to US Forces Installations and lead to confiscation of all installation access documents.

I acknowledge by my signature that I have read and understand the policy, requirements, and responsibilities above.

58. (Print) Last, First, MI:

64. Personal Access in Force Protection Condition:

CHARLIE DELTA

65. Vehicle Access in Force Protection Condition:

CHARLIE DELTA NO VEHICLE

66. Escort Privileges:

NO YES

67. Areas, Gates, and Base Privileges Granted (other Remarks):

68. Category Classification:

CAT 1 - Foreign National CAT 2 - Foreign Military CAT 3 - Non Screened US CAT 4 - Screened US CAT 5 - Commander’s Exception

72. Verifying Documents enclosed:

Copy of Passport (photo, data and residency)

Copy of CAC (front & back, if applicable)

Copy LOI, LOA or Orders Copy Kuwait Entry Visa with entry stamp Copy of Kuwait or GCC driver’s license Copy of Home of Record driver’s license RA Signature Verification (COR) Exception to Policy (completed and signed) Original Sponsor Letters (English and Arabic) Contractor Sponsor Letters (English and Arabic) Kuwait CID Cover Letter Contract Validation Letter (Khabari Crossing / SPOD) U.S. AD Retiree Limited Access Memorandum Copy of KMOI / KMOD / J-2 Pass Copy of US Permanent Resident Card Other: _________________________________

73. Vetting Date:

74. DBIDS Number of Applicant:

SECTION VII – Screening Office Use Only

75. Name of Screener:

76. Signature of Screener and Date:

77. Screening Status:

Approved

Rejected

Routed to PM

PAGE

ASG-KU PMO FORM 190-16.01 – Access Application (01FEB12) – ENCLOSURE 1 Replaces ASG-KU PMO Form 190.16.1 (01DEC10), which is obsolete