Request_for_Fort_Devens_Access_Control_Visitors_Pass.pdf

REQUEST FOR FORT DEVENS ACCESS CONTROL VISITORS PASS

SECTION BELOW IS FOR USE BY THE INSTALLATION ACCESS CONTROL OFFICE ONLY

PRIVACY ACT ADVISEMENT: The information requested is for the purpose of granting access to the Fort Devens Installation. The

SSN, required for record accuracy, is requested pursuant to EO 9397. All information that contains PII is protected as required.

1. APPLICANT INFORMATION:

Last Name: ______________________First Name: ________________________ Middle Name: _____________________

SSN: __________________________ Date of Birth (MM/DD/YY): ________________ Gender: M____ F ____

Are you a Registered Sex Offender? Yes No Do you have any felony convictions? Yes No

Place of Birth (City/State or Country):_________________________________________

2. REASON FOR VISIT: ______ Non-DoD Contractor/Vendor _____ Foreign National _____ Training / Appointment

______ Family Care Provider _____ Drill / Muster _____ Other ________________________

Have you received a Visitor Pass from Fort Devens within the past year? Yes ____ No____

How many days are you requesting? (01-30 days): _______________________

3. BUILDING NUMBER VISITING: _________________ POC NAME:__________________POC PHONE #:_______________

POCKDKDKD4. APPLICANT CERTIFICATION:

1. I understand that I must give Fort Devens Police consent to an initial and periodic background screenings prior to and after the issuance of an installation access pass. 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 requested 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 pass to prevent damage, or unnecessary wear, loss or theft.

4. I understand that I must immediately report any lost, damage or stolen pass to the Fort Devens Police.

5. All the information provided above is true and accurate and I have read all my responsibilities as an applicant for access to Fort Devens and its surrounding facilities.

(Applicant’s Printed Name) (Signature) (Date)

5. ISSUING OFFICIAL: APPROVED / ACCESS DENIED

Pass #:_______________________________

Vetting results: Renewal ____ NCIC Hit(s) ____ NIR ____ Expiration Date: _______________________ Escort Required: Yes____ No____

FBI:______________________ Category Letter for Access Denial:_________ SID:______________________ Charge(s): _________________________________________________________ SID: ______________________ _________________________________________________________

(Issuing Official’s Printed Name) (Signature) (Date)