BASE ACCESS REQUES1.pdf

MALE (1) AMERICAN INDIAN / ALASKA NATIVE (2) ASIAN (3) WHITE (1) HISPANIC / LATINO

FEMALE (4) BLACK / AFRICAN AMERICAN (5) NATIVE HAWAIIAN / OTHER PACIFIC ISLANDER (2) NOT HISPANIC / LATINO

7. CURRENT ADDRESS AND PHONE NUMBER

7a. NUMBER AND STREET (Include Apartment No.) 7b. CITY 7c. STATE 7d. ZIP CODE 7e. PHONE NUMBER

APPLICANT'S SIGNATURE

9a. COMPANY NAME 10a. SPONSOR NAME 11a.

DAILY (Mon- Fri) 9b. GENERAL CONTRACTOR 10b. SPONSOR UNIT

WEEKLY (1-2 times per week) 9c. COMPANY CONTACT NUMBER 10c. SPONSOR CONTACT NUMBER

MONTHLY (1-2 times per month) 9d. JOB SITE 10d. SPONSOR SIGNATURE

9e. START DATE 11b. ACCESS EXPIRATION DATE

NO

PREVIOUS EDITION IS OBSOLETE. MS Excel 2007SF FORM 90, 3 July 2018

12. SCAN DRIVERS LICENSE IN THIS SPACE.

1. DATE OF REQUEST (YYYYMMDD)

2. NAME OF APPLICANT (Last, First, Middle(s), Alias)

3. SEX 5. RACIAL CATEGORY (X one or more) 6. ETHNIC CATEGORY

12. PERSON COMPLETING THIS REQUEST

12c. SIGNATURE12b. RANK12a. NAME (Last, First, Middle Name(s)) 12d. TITLE

14. DEROGATORY FINDINGS

4. DATE OF BIRTH (YYYYMMDD)

YES

BASE ACCESS REQUEST

AUTHORITY: Title 10 United States Code, Sections 504, 505, 508, and 12102; E.O. 9397.

PRINCIPAL PURPOSE: To determine eligibility of a prospective contractor to be allowed access into an Armed Forces of the United States intsallation.

ROUTINE USES: Information collected on this form may be released to law enforcement agencies engaged in the investigation or prosecution of acriminal act or the enforcement or implementation of a statute, rule, regulation or order; to any component of the Department of Justice for the purpose of representing the DoD.

DISCLOSURE: Voluntary; however, failure of the applicant to complete this form may result in refusal of access into an Armed Forces of the United States intsallation.

PRIVACY ACT STATEMENT

SECTION IV - (Frequency of Visits)

The data are for OFFICIAL USE ONLY and will be maintained and used in strict confidence in accordance with Federal law and regulations. Making a knowing and willful false statement on this Form may be punishable by fine or imprisonment or both. All information provided by you, which possibly may reflect adversely on your past conduct and performance, may have an adverse impact on your clearance for base access.

The person described above has applied for access to a secure military installation therefore a LEIN check is required for installation access to be granted.

12e. Agency: 110th Security Forces Squadron 12f. Agency Address: 34 Sabre Street, Battle Creek, MI 49035 12g. ORI#: MIAF00400

12h. LEIN COMPLETED DATE (YYYYMMDD)

PLEASE EMAIL COMPLETED FORM TO: usaf.mi.110-atkw.list.sfs-pass-and-id@mail.mil

SECTION I - (Applicant's Personal Information)

SECTION II - (Contractor/Vendor Info) SECTION III - (Sponsor Info)

SECTION V - (To be completed by Security Forces Pass and ID member completing records check)

8. I HEREBY CONSENT TO A CRIMINAL HISTORY CHECK AS REQUIRED

TO GAIN ACCESS TO A MILITARY INSTALLATION.

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