TE-S - Sample LV-DES-LAC-APPLICATION.pdf

MIDDLE

SPONSOR INFORMATION

SPONSOR CERTIFICATION: I cer tify that the applicant meets the justification requirements above for access pr ivileges. Fur ther -more, I certify that the applicant requires an access control credential as indicated above in order to visit, perform assigned duties or conduct official business on Fort Leavenworth.

Sponsor Signature / Date Printed Name and Telephone Number

(Invalid if incomplete) (Invalid if incomplete)

APPROVED____ DISAPPROVED____

Issuing Official Printed Name Issuing Official Signature / Date

LOCAL ACCESS CREDENTIAL (LAC) APPLICATION

DIRECTORATE OF EMERGENCY SERVICES (DES)

FORT LEAVENWORTH, KS

(Please Print Legibly)

LAST NAME FIRST NAME MIDDLE

Date of Birth (DD/MM/YY)

APPLICANT INFORMATION

SS # DL # DL State

ADDRESS STATE ZIP

PLACE OF BIRTH

PHONE

GENDER

FLK VCC Form-01 Rev 3/2016

PURPOSE INFORMATION

PURPOSE

VISIT DURATION FROM ____/____/____ TO ____/____/____ CONTRACT EXPIRATION DATE ____/____/____

CRIMINAL HISTORY

Have you ever been ARRESTED, CONVICTED, sent through DIVERSION, etc for any offense other than parking/moving violations?

YES NO

If yes, please explain:

DATA REQUIRED BY THE PRIVACY ACT OF 1974 (5 U.S.C. 552a)

AUTHORITY: 10 U.S.C. Section 3012

PRINCIPLE PURPOSE(S): To provide the name, SSN, home address and telephone number to Fort Leavenworth security personnel who have the need to know in the performance of their official duties.

ROUTINE USES: To Federal, State, and local activities for use in security background checks.

DISCLOSURE: Mandatory. If not provided, the individual would not be approved for a LAC or pass.

FOR OFFICE USE ONLY

NCIC-III (Y/N) WANTS/WARRANTS (Y/N) BAR LIST (Y/N) KANSAS HOT FILES (Y/N)

OPERATOR INITIALS

CITY

EMAIL EMPLOYER

LAST NAME FIRST NAME

ORGANIZATION / UNIT

EMAIL

REC’D

NOTIFIED

ISSUED

LAC ELLIGIBILITY: This application must be endorsed by an individual approved as a sponsor for Fort Leavenworth. The applicant must demonstra te the need for a valid, recurring need to access Fort Leavenworth. For the purposes of this document, recurring is defined as at least 1 day per week. LACs will not be issued for a duration less than 90 days. THE ORIGINAL OF THIS COMPLETED FORM MUST BE SUBMITTED BY THE SPONSOR.

NOTE: All fields must be filled in completely. The sponsor will be notified when the application has been approved. The applicant will have 30 days after notification to receive the ID. After 30 days the process must be restarted.

(Completed by Applicant)

(Completed by Applicant)

(Completed by Sponsor)

(Completed by Sponsor)

CAC ID # EXPIRATON ____/____/____

TYPE OF ACCESS

(you may select more than one)

DUTY DAY (M-F 0500 -1800) WEEKENDS (S-S 0500-1800) FULL ACCESS (24/7)

DESTINATION/ CONTRACT #

NOTES:

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Sticky Note Employers primary phone number.

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Sticky Note Employer's primary email address

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Sticky Note You must list any instance of arrest, conviction, or diversion from any time. Failure to do so may result in application denial.

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Sticky Note Must place full middle name if the applicant has one, failure to list may result in application denial.

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Sticky Note Social Security Number

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Sticky Note DL# = driver's license number

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Sticky Note State two-digit abbreviation, this example is "KS = Kansas"

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Text Box

DO NOT PROCEED PAST THIS AREA.

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Pencil

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Sticky Note Full, legal last name of applicant

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Sticky Note Full, legal first name of applicant

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FORT LEAVENWORTH INSTALLATION ACCESS CREDENTIAL

ACKNOWLEDGEMENT STATEMENT

1. I understand that I must give Fort Leavenworth Access Control Centers consent to an initial and peri-odic background screenings pr ior to and after the issuance of an installation access credential.

Failure to do so will result in the termination of the application process. I further understand that these background screenings will determine my eligibility for access and continued access during the term of my visit.

2. I understand that my access may be revoked at anytime without reason or notice.

3. I understand that I must properly care for my credential to prevent damage, or unnecessary wear.

4. I understand that it is prohibited to allow someone to tailgate (following someone else in/out of gates without using a credential), or allow someone else to use my credential.

5. I understand that my credential must be turned in to the Installation Access Office once it has expired or further use is not required.

6. I understand that I must immediately report any lost, damaged or stolen credential to my sponsor and the military police.

7. I understand that my credential must be controlled at all times. If you have and or know where your credential is, then it is considered secured! If your credential is lost or unrecoverable, please notify your sponsor immediately.

8. The carrying or storage of privately owned weapons, explosives, and ammunition on Army installa-tions is prohibited unless authorized by the Senior Commander.

9. I have read and understand the instructions listed above.

Applicant's Printed Name Date

Signature

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Sticky Note Read this page ONLY. Do NOT sign or date until instructed to do so at the Visitor Control Center at issuance.