Visitor Access Request.pdf

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Attached to
Building 269 Mold Remediation Services
Solicitation number
W50S72-26-Q-7204
Issued by

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This is an access request form for non-Department of Defense ID cardholders seeking unescorted access to Sioux City Air National Guard Base. The sponsor must provide the names, driver's license or state ID numbers, states, companies, dates of birth, and Social Security numbers for all individuals requiring installation access, including those under 18 years old. Visitors under 18 may enter only when escorted by an approved adult. The form establishes seven criminal history disqualifiers that render access unfavorable: inability to confirm U.S. citizenship or immigration status, being barred from military installations, active wanted status by federal or civil law enforcement, firearms or explosives convictions within three years, incarceration for 12 months or longer within three years, convictions for serious crimes including espionage, sabotage, treason, terrorism, murder, sexual assault, armed assault/robbery, rape, child molestation, or drug trafficking, and appearance on federal watch lists or hit lists for criminal or terrorist activity.

The sponsor must acknowledge responsibility for advising visitors over 18 to carry state-issued identification and must ensure anyone driving on the installation provides a valid state driver's license, vehicle registration, and proof of insurance. The form includes a signature and date block for the sponsor and a separate security forces personnel section for vetting individuals, recording vetting dates, and documenting additions to the Entry Authorization List with block ranges and dates. The form accommodates up to 19 individuals for access request submission.

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Sioux City ANGB Access Request Letter (For Non-DoD ID Cardholders Only)

Sponsor Name:

Bldg(s) /Area Requesting:

Requested Date (s) / Installation Access:

In preparation to grant un- escorted acce information below. This information is re installation access. Procedure:

1. Sponsor must list everyone who may under the age of 18 may enter the in

2. Criminal History checks are considere

a. U.S. citizenship or immigration s

b. Barred from entry/access to any

c. Wanted by federal or civil law en

d. Conviction of firearms or explosi

e. Incarcerated for 12 months or lo

f. Conviction of espionage, sabotag child molestation, drug possessio

g. Name appears on any federal ag

Last Name, First Name, MI Drive or Sta to ss to individuals on Sioux City ANGB, you will need to provide the quired to conduct a criminal history check which must be favorable for need access to the installation, to include anyone under the age of 18. Visitors stallation when escorted by an adult who has been granted access.

d favorable if they do not contain any of the following disqualifiers:

tatus cannot be confirmed.

military installation or facility.

forcement authorities, regardless of offense or violation.

ves violation within the past three years.

nger within the past three years, regardless of the offense or violation.

e, treason or terrorism, murder, sexual assault, armed assault/robbery, rape, n with the intent to sell, or drug distribution.

ency’s “watch list” or “hit list” for criminal behavior or terrorist activity.

r’s License # te Issued ID #

State Company Date of Birth SSN #

Last Name, First Name, MI Driver’s License # or State Issued ID #

State Company Date of Birth SSN #

4. I understand it is my responsibility to advise my visitors that anyone over the age of 18 must have a state issued ID.

5. I understand that anyone driving on the installation will be required to provide a valid, state issued driver’s license, valid vehicle registration, and valid proof of insurance.

Sponsor’s Signature Date

============================ FOR SECURITY FORCES PERSONNEL ONLY (BELOW) ============================

Blocks through Vetted By:

Date:

Blocks through Vetted By:

Date:

Blocks through Vetted By:

Date:

Blocks through Added to EAL By:

Date:

Blocks through Added to EAL By:

Date:

Blocks through Added to EAL By:

Date:

Sponsor Name:
Buildings Requesting Access:
Last Name First Name MI1:
Drivers License or State Issued ID 1:
State1:
Company1:
Date of Birth1:
Contractor or Delivery CD1:
Last Name First Name MI2:
Drivers License or State Issued ID 2:
State2:
Company2:
Date of Birth2:
Contractor or Delivery CD2:
Last Name First Name MI3:
Drivers License or State Issued ID 3:
State3:
Company3:
Date of Birth3:
Contractor or Delivery CD3:
Last Name First Name MI4:
Drivers License or State Issued ID 4:
State4:
Company4:
Date of Birth4:
Contractor or Delivery CD4:
Last Name First Name MI5:
Drivers License or State Issued ID 5:
State5:
Company5:
Date of Birth5:
Contractor or Delivery CD5:
Last Name First Name MI6:
Drivers License or State Issued ID 6:
State6:
Company6:
Date of Birth6:
Contractor or Delivery CD6:
Last Name First Name MI7:
Drivers License or State Issued ID 7:
State7:
Company7:
Date of Birth7:
Contractor or Delivery CD7:
Last Name First Name MI8:
Drivers License or State Issued ID 8:
State8:
Company8:
Date of Birth8:
Contractor or Delivery CD8:
Last Name First Name MI9:
Drivers License or State Issued ID 9:
State9:
Company9:
Date of Birth9:
Contractor or Delivery CD9:
Last Name First Name MI10:
Drivers License or State Issued ID 10:
State10:
Company10:
Date of Birth10:
Contractor or Delivery CD10:
Last Name First Name MI11:
Drivers License or State Issued ID 11:
State11:
Company11:
Date of Birth11:
Contractor or Delivery CD11:
Last Name First Name MI12:
Drivers License or State Issued ID 12:
State12:
Company12:
Date of Birth12:
Contractor or Delivery CD12:
Last Name First Name MI13:
Drivers License or State Issued ID 13:
State13:
Company13:
Date of Birth13:
Contractor or Delivery CD13:
Last Name First Name MI14:
Drivers License or State Issued ID 14:
State14:
Company14:
Date of Birth14:
Contractor or Delivery CD14:
Last Name First Name MI15:
Drivers License or State Issued ID 15:
State15:
Company15:
Date of Birth15:
Contractor or Delivery CD15:
Last Name First Name MI16:
Drivers License or State Issued ID 16:
State16:
Company16:
Date of Birth16:
Contractor or Delivery CD16:
Last Name First Name MI17:
Drivers License or State Issued ID 17:
State17:
Company17:
Date of Birth17:
Contractor or Delivery CD17:
Last Name First Name MI18:
Drivers License or State Issued ID 18:
State18:
Company18:
Date of Birth18:
Contractor or Delivery CD18:
Last Name First Name MI19:
Drivers License or State Issued ID 19:
State19:
Company19:
Date of Birth19:
Contractor or Delivery CD19:
Date Signed: []
Dates Requested From:
Dates Requested To:

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