148FW Form 66 Application Release (Fillable).pdf

APPLICATION RELEASE FORM

PRIVACY ACT STATEMENT

1. AUTHORITY: Title V10-01. 64GT 44704 and Executive Order 9397.

2. PURPOSE: Information provided will be entered into the Criminal Justice Communication Network.

3. ROUTINE USES: To determine fitness for 148thFighter Wing installation access

4. DISSCLOSURE: Voluntary; however, if SSN is not provided, installation access may be denied.

In connection with my request to enter the 148th Fighter Wing, I understand that background investigation checks are to be made on me including, criminal convictions, motor vehicle, and other reports. Further, I understand that the 148FW will obtain information from various Federal, State and other agencies which maintain records concerning my past activities relating to my driving, criminal, and or civil claims.

I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so. This authorization and consent shall be valid in original or electronic form. I understand I will be denied entry to the 148FW for failure to consent to a criminal history check. See reverse side of form for acceptable forms of ID when entering 148FW. By submitting this form, you agree to this agency conducting a criminal history check prior to being allowed access to the installation.

**CAREFULLY PRINT NAME TO ELIMINATE SPELLING ERRORS DURING CRIMINAL BACKGROUND CHECK**

Section I. TO BE COMPLETED BY PERSON REQUESTING ACCESS TO THE 148 FW INSTALLATION First Name Middle Name Last Name

Other Names Used Company Name

Contact Number Sex: Male Female

Date of Birth Social Security Number

INABILITY TO CONDUCT A CRIMINAL BACKGROUND CHECK DUE TO INCOMPLETE OR ILLEGIBLE INFORMATION WILL

RESULT IN A DENIAL OF ACCESS DETERMINATION

Section II. TO BE COMPLETED BY SQUADRON REPRESENTATIVE SPONSORING/REQUSTING ACESS Reason Requesting Access to Installation BLDG# Base Location

Start Date End Date

148FW Sponsor Signature

Does this individual need a Contractor Badge: Yes No *Only individuals needing installation access greater that 30 days and greater than five days per month are eligible for contractor badges; all others will be given a temporary pass

PROCEDURES FOR FILING REQUEST FORM

- Scan and encrypt document. Forward encrypted document to the following email address: 148fw.sfs.visitoraccess@us.af.mil

- Submit requests for vetting no later than 3 business days before expected start date to allow for proper identification and fitness determination.

- The sponsor will only receive an email if the installation access request has been denied.

PREVIOUS EDITIONS ARE OBSOLETE PRIVACY ACT INFORMATION: The information in this form is FOR OFFICIAL USE ONLY. Protect IAW The Privacy Act of 1974

148FW FORM 66, 20220310

mailto:148fw.sfs.visitoraccess@us.af.mil

REAL ID ACT. As of 15 Sept 2016, all vendors, contractors, and other non-credentialed visitors will be denied unescorted access without approved credentials for back ground checks or authorized escorts. However, existing Contracts/EAL’s/DBIDS cards will be accepted until Contract/EAL/DBIDs completion dates. Please work with your 148th Fighter Wing contact to provide approved and authorized credentials. See list below. Any questions or concerns please contact the authorized individuals requesting your services.

Driver’s Licenses and Identification cards issued by any state or territory that is not compliant with REAL ID Act of 2005 will not be accepted for identity proofing for unescorted access to Air Force installations and facilities. Enhanced Driver’s Licenses (EDL) from noncompliant States/Territories will continue to be accepted. EDLs are marked as “enhanced driver license” and bear a small red, white, and blue U.S. Flag logo on the ID.

The following forms of ID are accepted for ID proofing visitors who are requesting entry to the 148 FW:

• Enhanced MN Driver’s License (DL) or any state REAL ID Act compliant DL

• United States Passport

• Permanent Resident Card/Alien Registration Receipt Card (Form I-551)

• Employment authorization document with photograph (Form I-766)

• Non-DMV Identification card issued by Federal, State, or local government agencies provided it contains a photo and biographic information such as name, date of birth, gender, height, eye color, and address

• State/Territory DMV Driver’s license/ID card compliant with REAL ID Act of 2005

• U.S. Coast Guard Merchant Mariner Cards/Credentials

• PIV or Federally-Issued PIV-1 Cards issued by the Federal Government

• PIV-I card issued by Non-Federal Government entities

• DHS “Trusted Traveler Cards” (Global entry, NEXUS, SENTRI, FAST)

• Merchant Mariner card issued by DHS/ United States Coast Guard (USCG)

• Border Crossing Card (Form DSP-150)

• U.S. Certificate of Naturalization/Certificate of Citizenship (Form N-550)

• U.S. Permanent Resident Card (Form I-551)

• U.S. Refugee travel document issued by DHS containing a photograph

• Foreign Government Issued Passport

Those visitors who do not produce one of the accepted forms of identity documentation for installation access will not be permitted to enter the installation without an approved escort. If an individual is escorted, the sponsor is required to be physically present with the individual for the duration of the visit on the installation.

All individuals requesting access to the 148th Fighter Wing are required to be vetted through the National Crime

Information Center (NCIC) Database. Disqualifiers are outlined in DANGBI 31-201:

3.3.1. Refusal to submit to criminal history check.

3.3.2. U.S. citizenship, immigration status, or Social Security Account Number cannot be verified.

3.3.3. Barred from entry/access to any military installation or facility.

3.3.4. Wanted by federal or civil law enforcement authorities.

3.3.5. Conviction of firearms or explosives violation, aggravated assault, armed robbery, felony drug possession, drug possession with intent to sell, or drug distribution within the past 5 years.

3.3.6. Conviction of espionage, sabotage, treason, terrorism, murder, rape, sexual assault.

3.3.7. Name appears on any federal agencies “watch” or “hit list” for criminal behavior or terrorist activity.

3.3.8. Individuals currently serving parole or probation for the felony offenses.

*The Installation Commander reserves the right to deny access to any individual at any time

148FW FORM 66, 20220310, (BACK)