USAG-ALC-Access-Form-191.pdf

FORM MUST BE TYPE WRITTEN

HAND WRITTEN MAY NOT BE ACCEPTED

USAG/ALC Installation Access Request

□GOVERNMENT □RESIDENT □CONTRACTOR □VISITOR □OTHER ____________________

Applicant’s Full Name (Last, First, Middle Name) Height Weight Eye Color Hair Color

Social Security Number Sex Driver’s License Number and St. Date of Birth Male □ Female □

Race Ethnicity Citizenship Status

□ American Indian/Alaskan Native

□ Asian/Pacific Islander

□ Black □ White □ Unknown

□ Hispanic

□ Not of Hispanic Origin

□ Unknown

□ U.S. □ Other Specify Below □ Married

□ Single

□ Divorced

□ Permanent Resident Card □ Workers Authorization Card □ Naturalization Certificate □ Non U.S. Passport □ N/A Card/Certificate/Passport Number:

Home Address:

Best Phone Number: Work Phone Number:

Company Name and Full Address:

SPONSOR INFORMATION

Sponsoring Organization/Unit:

Sponsors Name(Print): Sponsors Rank:

Sponsors Status:

Contract Number:

Sponsors Work Phone Number: Sponsors Home Number: Expiration Date

(MM-DD-YYYY)

Sponsors Signature:_____________________ Signature Date:

Reason access is needed? If more space is needed please continue on additional paper. (Attach any important documents)

FOR INTERNAL USE ONLY

Notes:

Directorate of Emergency Services, NCIC Operator □ Cleared □ Not Cleared

Date of NCIC Check: (MM-DD-

YYYY)

Installation Access Control Officer (DES STAMP)

□ Access Approved □ Access Denied _________________________ (Signature of Access Control Officer)

Date Processed: (MM-DD-YYYY)

□ On gate Vetted List/AIE Database Badge: □ One day Pass □ Badge Expiration Date __________________________

Date Issued: (MM-DD-YYYY)

Data Required By the Privacy Act of 1974 Authority 5 U.S.C. 301, Dept.

Regulations 10 U.S.C. 3013 Principal Purpose(s): In addition to those disclosures generally under 5 U.S.C. 552a(b) of the Privacy Act, this information contained therein may be disclosed outside DOD as a routine use pursuant to 5 U.S.C. 552a(b)(3), AR 340-21, Para 3-2 Disclosure: VOLUNTARY, individual may disclose his or her personal information; however, failure to provide your SSN and personal data may delay or preclude access to the installation. (Authorized under AR 190-45, AR 190-5, MDW requirements, andU.S.C.3013)

FGGM FORM 191-001-R-E

Reason for access:

Arrival Date: Departure Date:

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PORT REPUBLIC, MD 20676