Attach-7-125FW Form 2 Installation Access Request dated Sep 2022.pdf

125FW FORM 2, JULY 2021 PAGE 1 OF 2

REQUEST FOR INSTALLATION ACCESS TO 125TH FW

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY: Title 5, USC 3331, 552, 552a; 10 USC 10204; Executive Orders (EO) 10450, 10865, and 12333.

PRINCIPAL PURPOSE: The information requested is for the purpose of granting access to the 125th FW Installation. ROUTINE USES: Basis for determination of qualifications and background information for eligibility for access to the Installation. The Social Security Number (SSN), required for record accuracy, is requested pursuant to EO 9397.

DISCLOSURE: Providing requested information, to include your SSN is voluntary. However, your access may not be granted if all requested information is not provided. Contents shall not be disclosed, discussed, or shared with individuals unless they have a direct need-to-know in performance of their official duties. Deliver this document directly to the intended recipient. DO NOT drop off or send to a third-party. This document contains personal or privileged information and should be treated as "For Official Use Only (FOUO)".

PART I - APPLICANT INFORMATION

a. LAST NAME: b. FIRST NAME: c. MIDDLE INITIAL:

d. GRADE/RANK/STATUS: e. SOCIAL SECURITY NUMBER: f. DOB:

g. GENDER: Male Female h. E-MAIL ADDRESS:

i. PHONE NUMBER : j. EMPLOYER:

k. DRIVER'S LICENSE / ID # STATE Exp Date. l. RACE:

M. Where were you born:

Of what country(ies) are you a citizen?

Are you a Resident Alien(circle): Yes / No

If yes, provide Resident Alien Number:

Are you an alien with temporary work authorization(circle): Yes / No

If yes, provide Employee Authorization Document (EAD) Number:

****Please be advised that you may be asked for further documentation and your background checks can take up to a minimum of 10 business days.

It is punishable by law to provide any false information or documentation to a law enforcement agency. Doing so could result in apprehension/arrest.

PART II - VISITOR INFORMATION

a. REQUESTED DATE(S) / TIME OF VISIT: FROM : TO:

b. PURPOSE OF YOUR VISIT:

CONTRACTOR

SPECIAL EVENT (Specify below):

SITE VISIT

VENDOR

NEWS MEDIA

PART III - VEHICLE

a. MAKE: b. MODEL: c. COLOR: d. PLATE #:

PART IV - CONTACT/SUPPORT PERSONNEL

a. CONTRACT/GOVERNMENT BILL OF LADING #:

b. GOVERNMENT ORGANIZATION/BUSINESS SUPPORTED:

c. CONTRACT EXPIRES: d. COR/SUPERVISOR:

PART V - GOVERNMENT SPONSOR'S CERTIFICATION

I certify that the applicant meets the justification requirements as indicated in Part IV above for access privileges.

Furthermore, I certify that the applicant requires an access control card as indicated above in order to perform assigned duties or conduct official business on the 125th Fighter Wing Installation

a. COR/SUPERVISOR/PHONE NUMBER (Invalid if Incomplete)

b. SUPERVISOR/SPONSOR SIGNATURE (Invalid if Incomplete)

125FW FORM 2, JULY 2021 PAGE 2 OF 2

PART VI - ISSUING OFFICE

SECTION BELOW IS FOR USE BY INSTALLATION ACCESS CONTROL OFFICE ONLY

a. APPROVED

b. DISAPPROVED

c. ACTION TAKEN (Specify below)

a. APPROVING OFFICIAL PRINTED NAME

b. APPROVING OFFICIAL SIGNATURE

DATE

INSTALLATION ACCESS CARD/PASS

ACKNOWLEDGEMENT STATEMENT

1. I understand that I must give the 125th SFS Visitor Control Centers consent to an initial criminal history and periodic background screenings prior to and after the issuance of an installation access card/pass by completing 125FW Form 2. 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.

a. I understand that my access may be revoked at any time without reason or notice.

b. I understand that I must properly care for my cards/pass to prevent damage, or unnecessary wear.

c. I understand that it is prohibited to allow someone else to use my card/pass.

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

e. I understand that I must immediately report any lost, damaged or stolen card/pass to my sponsor and the base Security Forces.

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

2. I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

I understand that making false statements on the 125FW Form 2 or providing false or fraudulent documents in support of the request for access is a felony punishable by up to five years in prison under 18 U.S.C. § 1001.

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

APPLICANT'S PRINTED NAME

APPLICANT'S SIGNATURE