190-17 Restricted Area - Proximity Badge Request (01 Jun 22).pdf

FOR VCC USE ONLY

CUI

RESTRICTED AREA / PROXIMITY BADGE REQUEST

M.I.:FIRST:LAST: _____________________________________ _________________________________ ________ SUFFIX: _______

DIRECTORATE / ORGANIZATION / COMPANY: ___________________________________________________________________________

) U.S. CITIZEN: YES NO (IF NO – PERM. RES CARD OR FN SCREEN EXP DATE: _____________________________

DOB: _____SEX: ___HEIGHT (ft & in): _____ EYES: _______HAIR: _____________ ______ ________ _____ _________________

ADDRESS: ________________________________________CITY___________________________________STATE_______ZIP_________

PERSONAL PHONE: _________________________________________ WORK PHONE: _______________________________________

NOTE: ALL BADGES/PASSES MUST BE TURNED IN OR RENEWED BY THEIR EXPIRATION DATE.

DATE: SIGNATURE: ________________________________________________________________________ ______________________

FOR QEF ACCESS PURPOSES ONLY

AREA: ADMIN TELE TLW

AUTHORIZING OFFICIAL: __________________________________________ SIGNATURE: ____________________________________

FOR WATER TREATMENT FACILITY ACCESS PURPOSES ONLY

AUTHORIZING OFFICIAL: __________________________________________ SIGNATURE: ____________________________________

VALID PHOTO ID VERIFICATION

TYPE: ________________________________ #: ________________________________________ EXP DATE: ____________________

PBA/NAF EMPL

PBA RESTRICTED AREA BADGE INFORMATION

CONTRACTOR VISITOR

Controlled By: DES CUI Category: PRVCY

LDC: FED ONLY

POC: Shannon Stowell; 870-540-4080

PBA FORM 190-17 CUI 01 JUN 2022

BADGE # ISSUE DATE ACCESS ESCORT TYPE EXPIRE DATE SPONSOR

PRIVACY ACT STATEMENT:

AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; Army Regulation 190-13, The Army Physical Security Program; 10 U.S.C. 1124 and 5 U.S.C. 4502.

PRINCIPAL PURPOSE(S): To support Department of the Army physical security and access control programs; Information Assurance program; to record personal data and vehicle information registered with the Department of the Army; to provide a record of security/access badges issued; to restrict entry to installations and activities; to ensure positive identification of personnel authorized access to restricted areas; to maintain accountability for issuance and disposition of security/access badges and for producing installation management reports.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:

The DoD 'Blanket Routine Uses' also apply to this system of records.

DISCLOSURE: Disclosure is voluntary. However, failure to provide this information may result in denial of entry to Pine Bluff Arsenal.

For additional information regarding privacy practices see System Of Record Notice (SORN) A0191-13 OPMG at http://dpcld.defense.gov/Privacy/

SORNsIndex/DOD-wide-SORN-Article-View/Article/569989/a0190-13-opmg/ http://dpcld.defense.gov/Privacy/