ELTY_648_C.pdf

Application Date Areas of TYAD to be Visited

1 of 2ELTY FORM 648-C, DEC 2014

Request for Access to Tobyhanna Army Depot Use in accordance with " Directive Type Memorandum (DTM)" 09-012 " Interim Policy Guidance for DoD Physical Access Control" dated 22 Apr 14

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 United States Code, Section 3013

PRINCIPAL PURPOSE(S): In conjunction with "Directive Type Memorandum (DTM)" 09-012 "Interim Policy Guidance for DoD Physical Access Control", dated 22 Apr 14, this form is intended to ensure that force protection measures are implemented for all non-DoD - credentialed personnel who request access to the installation.

ROUTINE USES: To control and maintain force protection requirements.

DISCLOSURES: Voluntary civilian. Failure to provide information deemed "mandatory" may result in a processing delay of your request for access or a denial of your request.

Date of Anticipated Visit or Yellow Contractor Badge Expiration Date

Reason for Request for Criminal History Background Check

Street Address

Home Telephone Number

First Name

City

Tobyhanna Federal Employee POC

Name Of Company (No Abbreviations)

Company POC Phone Number

This Area To Be Completed Only If You Are A Contractor or Vendor

Company Address

Proponent Office is ELTY-ISR-S

Last Name

Sex

Middle Name

Other Names Used

Zip Code

Race Country Place of Birth

Date of Birth: Social Security Number Driver's License State of Issurance Driver's License Number

Tobyhanna Federal Employee POC Phone Number

Tobyhanna Federal Employee POC Directorate

Tobyhanna Federal Employee Point of Contact E-mail Address

City Zip Code

Company POC Fax Number Company POC Email address

CRIMINAL HISTORY BACKGROUND CHECK RELEASE AND CONSENT

I hereby authorize the Tobyhanna Army Depot Security Branch to receive any criminal history/background information pertaining to me which may be in the files of any Federal, State or Local criminal justice agency/organization. I understand that a criminal history background check will be used to determine access to Tobyhanna Army Depot and that access to Tobyhanna Army Depot can be revoked at any time.

PLEASE TAKE NOTICE THAT ONE OR MORE CRIMINAL BACKGROUND REPORTS PURSUANT TO THE FAIR CREDIT REPORTING ACT, AS AMENDED, 15 U.S.C. 1681 ET SEQ, MAY BE OBTAINED FOR THE PURPOSES OF ACCESS TO TOBYHANNA ARMY DEPOT. SHOULD A DECISION TO DENY ACCESS BE MADE BASED EITHER IN PART OR IN WHOLE ON THAT REPORT, THE REPORTING AGENCY THAT PROVIDED THE INFORMATION PLAYED NO ROLE IN THE DECISION.

Information provided by you on this form will be furnished to Tobyhanna Army Depot's Security Branch to obtain information in connection with an investigation to determine access to Tobyhanna Army Depot. This information is collected for national security and force protection purposes. Use of this form does not relieve any contractor of any requirement to perform a criminal background check or drug test.

State

State Place of Birth

StateCompany POC

(If not born within the U.S.) Provide U.S. Passport, Green Card, or Naturalization Certificate

Access to InstallationYellow Contractor Badge

Please check one of the following options

2 of 2ELTY FORM 648-C, Dec 2014

Please answer the following questions and report information truthfully; regardless of whether your case has been "sealed", expunged or otherwise stricken from the court record. The single exception to this requirement is certain convictions under the Federal Controlled Substances Act-cases for which the court has issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607.

If the answer is "yes" to any of these questions, please list the actual offense or violation (for example: theft, DUI, battery, etc).

1. Are you currently barred from ANY military installation?

If YES, for what offense (s)?

YES NO

3. Have you ever been charged with or convicted of a felony?

If YES, list the offense, date and jurisdiction.

4. Have you ever been charged with or convicted of a firearms, weapons, or explosives offense?

If YES, list the offense, date and jurisdiction.

5. Have you ever been charged with or convicted of any offense related to alcohol or drugs?

If YES, list the offense, date and jurisdiction.

6. In the last 7 years, have you been subject to a court martial or other disciplinary proceedings under the Uniform Code of Military Justice? (Include non-judical, Captains's mast, etc.) *If YES, list the offense, date and jurisdiction.

7. In the last 10 years, have you been arrested for, charged with, or convicted of any other offense not listed above? ( Include misdemeanors) Leave out traffic fines of less than $150 unless the violation was alcohol or drug related. If YES, list the offense, date and jurisdiction.

Name of Applicant (Print):_____________________________________

Signature:__________________________________

Date:__________________

APPLICANT CERTIFICATION

I certify that, to the best of my knowledge and belief, all of the information provided on this request for access to Tobyhanna Army Depot is true, correct, complete and made in good faith. I understand that false, fraudulent, or incomplete information may be grounds for the denial of my request or for the revocation of access to Tobyhanna Army Depot and may be punishable by fine or imprisonment. I understand that any information I provide may be investigated.

2. Have you ever been arrested for, charged with, or convicted of a sex offense? Are you a registered sex offender?

If YES, list the offense, date and jurisdiction.

9. Are you a United States Citizen?

10. Do you currently have or have you ever been issued a security clearance by the United States government?

If yes, please provide details on where the clearance was issued and the status of the clearance.

8. Are you currently on parole or probation? If YES, for what offense(s)?

Country of Citizenship Registration Number Expiration of your work permit

Offense date Jurisdiction

JurisdictionDateOffense

JurisdictionDate Offense

JurisdictionDate Offense

JurisdictionDate Offense

JurisdictionDateOffense

Status of ClearanceClearance Issued A Tobyhanna government issued badge is not a security clearance.

Date

If no, please list your country of citizenship, registration number, and the expiration date of your work permit.

D:\Users\melanie.a.janosky\Desktop\648-C Nov 11.xfdl melanie.a.janosky A pplication Date Areas of TYAD to be Visited

ELTY FORM 648-C, DEC 2014

Request for Access to Tobyhanna Army Depot Request for Access to Tobyhanna Army Depot Use in accordance with " Directive Type Memorandum (DTM)" 09-012 " Interim Policy Guidance for DoD Physical Access Control" dated 22 Apr 14 Use in accordance with " Directive Type Memorandum (DTM)" 09-012 " Interim Policy Guidance for DoD Physical Access Control" dated 22 Apr 14

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 United States Code, Section 3013 PRINCIPAL PURPOSE(S): In conjunction with "Directive Type Memorandum (DTM)" 09-012 "Interim Policy Guidance for DoD Physical Access Control", dated 22 Apr 14, this form is intended to ensure that force protection measures are implemented for all non-DoD - credentialed personnel who request access to the installation.

ROUTINE USES: To control and maintain force protection requirements.

DISCLOSURES: Voluntary civilian. Failure to provide information deemed "mandatory" may result in a processing delay of your request for access or a denial of your request.

Date of Anticipated Visit or Yellow Contractor Badge Expiration Date Reason for Request for Criminal History Background Check Street Address Home Telephone Number First Name City Tobyhanna Federal Employee POC Name Of Company (No Abbreviations) Company POC Phone Number This Area To Be Completed Only If You Are A Contractor or Vendor Company Address Proponent Office is ELTY-ISR-S Proponent Office is ELTY-RKC Last Name Sex Middle Name Other Names Used Zip Code Race Country Place of Birth Date of Birth:

Social Security Number Driver's License State of Issurance Driver's License Number Tobyhanna Federal Employee POC Phone Number Tobyhanna Federal Employee POC Directorate Tobyhanna Federal Employee Point of Contact E-mail Address City Zip Code Company POC Fax Number Company POC Email address

CRIMINAL HISTORY BACKGROUND CHECK RELEASE AND CONSENT

I hereby authorize the Tobyhanna Army Depot Security Branch to receive any criminal history/background information pertaining to me which may be in the files of any Federal, State or Local criminal justice agency/organization. I understand that a criminal history background check will be used to determine access to Tobyhanna Army Depot and that access to Tobyhanna Army Depot can be revoked at any time.

PLEASE TAKE NOTICE THAT ONE OR MORE CRIMINAL BACKGROUND REPORTS PURSUANT TO THE FAIR CREDIT REPORTING ACT, AS AMENDED, 15 U.S.C. 1681 ET SEQ, MAY BE OBTAINED FOR THE PURPOSES OF ACCESS TO TOBYHANNA ARMY DEPOT. SHOULD A DECISION TO DENY ACCESS BE MADE BASED EITHER IN PART OR IN WHOLE ON THAT REPORT, THE REPORTING AGENCY THAT PROVIDED THE INFORMATION PLAYED NO ROLE IN THE DECISION.

Information provided by you on this form will be furnished to Tobyhanna Army Depot's Security Branch to obtain information in connection with an investigation to determine access to Tobyhanna Army Depot. This information is collected for national security and force protection purposes. Use of this form does not relieve any contractor of any requirement to perform a criminal background check or drug test.

State State Place of Birth State Company POC (If not born within the U.S.) Provide U.S. Passport, Green Card, or Naturalization Certificate Access to Installation Yellow Contractor Badge Please check one of the following options ELTY FORM 648-C, Dec 2014 Please answer the following questions and report information truthfully; regardless of whether your case has been "sealed", expunged or otherwise stricken from the court record. The single exception to this requirement is certain convictions under the Federal Controlled Substances Act-cases for which the court has issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607.

If the answer is "yes" to any of these questions, please list the actual offense or violation (for example: theft, DUI, battery, etc).

1. Are you currently barred from ANY military installation?

If YES, for what offense (s)?

YES

NO

3. Have you ever been charged with or convicted of a felony?

If YES, list the offense, date and jurisdiction.

4. Have you ever been charged with or convicted of a firearms, weapons, or explosives offense?

If YES, list the offense, date and jurisdiction.

5. Have you ever been charged with or convicted of any offense related to alcohol or drugs?

If YES, list the offense, date and jurisdiction.

6. In the last 7 years, have you been subject to a court martial or other disciplinary proceedings under the Uniform Code of Military Justice? (Include non-judical, Captains's mast, etc.) *If YES, list the offense, date and jurisdiction.

7. In the last 10 years, have you been arrested for, charged with, or convicted of any other offense not listed above? ( Include misdemeanors) Leave out traffic fines of less than $150 unless the violation was alcohol or drug related. If YES, list the offense, date and jurisdiction.

Name of Applicant (Print):_____________________________________ Signature:__________________________________ Date:__________________

APPLICANT CERTIFICATION

I certify that, to the best of my knowledge and belief, all of the information provided on this request for access to Tobyhanna Army Depot is true, correct, complete and made in good faith. I understand that false, fraudulent, or incomplete information may be grounds for the denial of my request or for the revocation of access to Tobyhanna Army Depot and may be punishable by fine or imprisonment. I understand that any information I provide may be investigated.

2. Have you ever been arrested for, charged with, or convicted of a sex offense? Are you a registered sex offender?

If YES, list the offense, date and jurisdiction.

9. Are you a United States Citizen?

10. Do you currently have or have you ever been issued a security clearance by the United States government?

If yes, please provide details on where the clearance was issued and the status of the clearance.

8. Are you currently on parole or probation? If YES, for what offense(s)?

Country of Citizenship Registration Number Expiration of your work permit Offense date Jurisdiction Jurisdiction Date Offense Jurisdiction Date Offense Jurisdiction Date Offense Jurisdiction Date Offense Jurisdiction Date Offense Status of Clearance Clearance Issued A Tobyhanna government issued badge is not a security clearance.

Date If no, please list your country of citizenship, registration number, and the expiration date of your work permit.

patrick.clifford@dla.mil

Please check “Outside of Controlled Area” if you will be visiting non-mission-related areas of TYAD, such as military housing or The Landing.: Inside Controlled Area