Vetting Form Authorized 157CC July 2020.pdf

NEW HAMPSHIRE AIR NATIONAL GUARD

HEADQUARTERS 157TH AIR REFUELING WING

PEASE AIR NATIONAL GUARD BASE NEW HAMPSHIRE

Date of request:

Name:

Maiden Name:

D/O/B:

SSN:

(Last, First, MI)

(If applicable)

State: Drivers License #

Reason for requesting access:

Contractor/DBIDS Pass

Delivery/Service Provider

Veteran’s Clinic Access

AUTHORIZATION AND RELEASE

I hereby direct and authorize the 157th Air Refueling Wing to perform a record check of my person through the National Crime Information Center and Interstate Identification Index databases in order to determine my fitness for unescorted entry onto the installation of Pease Air National Guard Base.

I hereby release the 157th Air Refueling Wing, the State of New Hampshire, and the United States Air Force from any causes of action of any kind, nature, or description whatsoever, arising from the release of, or request for, my criminal record history.

X Signature of Applicant

FOR OFFICIAL USE ONLY (FOUO) information which must be protected under the Freedom of Information Act (5 U.S.C. 552) and/or the Privacy Act of 1974 (5 U.S.C. 552a). Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in disciplinary action, criminal and/or civil penalties. Further distribution is prohibited without the approval of the author of this message unless the recipient has a need to know in the performance of official duties.

“Citizen soldiers building the nation’s most respected Air National Guard Unit-serving America, New Hampshire, and community..in partnership with family and employer.”

As of 9 July 2020 (Previous Editions Obsolete)

SECURITY FORCES USE ONLY

IEC: Signature: Approved

Opr: Signature: Denied

State issued drivers license AND, or REAL ID, Enhanced ID (EDL), Government issued photo ID, US Passport, Federal employee, military, or Veteran Identification card.

(If completing form at the gate, provide ID to guard for review)