Attachment 4 - Base Access Form - Amendment 01.pdf
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- Solicitation number
- W50S6V25Q0012
About this file
This document is a Request for Visitor to Obtain Unescorted Access to Buckley Space Force Base form (Buckley SFB Form 128), designed to facilitate guest installation access for an individual. The form requires a sponsor (Steven Esworthyjones from 140 CS unit, DoD ID 1263813908) to request a one-day site visit on 7/24/2025, with the purpose of obtaining an unescorted access pass. The form includes sections for sponsor and guest information, and requires submission to Access Control Staff 72 hours prior to the requested visit, with the guest presenting a government/state ID to establish identity. The form is subject to the Privacy Act of 1974 and is used to assist security personnel in establishing a fitness determination through identity proofing and vetting.
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REQUEST FOR VISITOR TO OBTAIN UNESCORTED ACCESS TO BUCKLEY SPACE FORCE BASE
(THIS FORM IS SUBJECT TO THE PRIVACY ACT STATEMENT OF 1974)
AUTHORITY: 10 U.S.C. 8013; 5 U.S.C 552a PURPOSE: To assist security personnel in establishing a fitness determination through the identity proofing and vetting process.
INTENDED USE: To be utilized by personnel requesting to obtain guest installation access pass for unescorted access to Buckley Space Force Base (BSFB).
DISCLOSURE: Disclosure of requested information is voluntary, however failure to provide information may result in denial of request and the refusal by the 460th Security Forces Squadron, Installation Access Control Section to permit access to the installation.
INSTRUCTIONS
1. All information must be complete and in alphabetical order or the form will be denied.
2. Guest must present government/state ID in order to establish identity.
3. Sponsor must be registered in DBIDS prior to submitting form.
4. Must be submitted to Access Control Staff 72 hours prior to request.
SECTION I: SPONSOR INFORMATION
SPONSOR NAME (Last, First, MI) SPONSOR DOD ID NUMBER SPONSOR UNIT SPONSOR PHONE NUMBER
Visit Start Date (MM/DD/YYYY) Visit End Date (MM/DD/YYYY) Number of Days REASON FOR VISIT
SECTION II: GUEST INFORMATION
GUEST NAME (Last, First, MI) DOB (MM/DD/YYYY) DRIVERS LICENSE NUMBER STATE Approved (Yes/No
SECTION III: TO BE COMPLETED BY 460TH SECURITY FORCES INSTALLATION ACCESS CONTROL STAFF DATE NCIC CHECK CONDUCTED APPROVING OFFICIAL (Last, First, MI) SIGNATURE
BUCKLEY SFB FORM 128 Page # ____ of ____
| SPONSOR NAME Last First MIRow1: ESWORTHYJONES, STEVEN |
| SPONSOR DOD ID NUMBERRow1: 1263813908 |
| SPONSOR UNITSPONSOR DOD ID NUMBER Number of Days: 140 CS |
| SPONSOR PHONE NUMBERSPONSOR UNIT: 847-9346 |
| Number of DaysRow1: 1 |
| GUEST NAME Last First MI DOB MMDDYYYY DRIVERS LICENSE NUMBER STATE SSNRow1: |
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| Text1: Site Visit |
| Date2_af_date: 7/24/2025 |
| Date3_af_date: 7/24/2025 |
| Text4: |
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