Exhibit_G_-_ASG-KU_DES_Form_190-16.04_Enclosure_11.doc
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Exhibit G - ASG-KU DES Form 190-16.04 Enclosure 11
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ASG-KU NOTICE OF DELEGATION OF AUTHORITY
(Read Privacy Act Statement and instructions before completing form.)
DATE
PRIVACY ACT STATEMENT
AUTHORITY: AR 600-8-14, AR 600-8-104, and ASG-KU Installation Access Policy PRINCIPAL PURPOSE: To establish positive identification and signature verification of all personnel authorized as signatories for ASG-KU Installation Access and Vehicle Registration.
MANDATORY DISCLOSURE REQUIREMENT: Failure to provide the below requested information, including last four digits of the social security number, will result in denial of delegated signatory privileges. Personal information such as the last four digits of the social security number provide an individual with a unique identification and will be handled as OFFICIAL USE ONLY in accordance with Federal Statutes.
CONDITIONS APPLICABLE ON RECEIPT: I understand that the delegated signatory privileges requested by this document are valid only through the expiration date indicated.
COR/ACO/APPOINTING AUTHORITY
I assume full responsibility for the following individuals as signatories for ASG-KU Installation Access and Vehicle Registration.
LAST NAME, FIRST NAME, MIDDLE INITIAL
LAST 4 OF SSN
GRADE
RANK
SIGNATURE
INITIALS
UNIT IDENTIFICATION CODE
DODAAC/ACCOUNT NUMBER
DOD COMPONENT/ORGANIZATION
SERVICE
FORMCHECKBOX
ARMY FORMCHECKBOX
NAVY FORMCHECKBOX
USAF FORMCHECKBOX
USMC FORMCHECKBOX
US COAST GUARD
LOCATION
TELEPHONE NUMBER
EMAIL ADDRESS
AUTHORIZED REPRESENTATIVE(S)
LAST NAME, FIRST NAME, MIDDLE INITIAL
LAST 4 OF SSN
GRADE
RANK
SIGNATURE
INITIALS
DOD COMPONENT/ORGANIZATION
SERVICE
CONTRACT NUMBER(S)
EXPIRATION
LOCATION
TELEPHONE NUMBER
EMAIL ADDRESS
LAST NAME, FIRST NAME, MIDDLE INITIAL
LAST 4 OF SSN
GRADE
RANK
SIGNATURE
INITIALS
DOD COMPONENT/ORGANIZATION
SERVICE
CONTRACT NUMBER(S)
EXPIRATION
LOCATION
TELEPHONE NUMBER
EMAIL ADDRESS
LAST NAME, FIRST NAME, MIDDLE INITIAL
LAST 4 OF SSN
GRADE
RANK
SIGNATURE
INITIALS
DOD COMPONENT/ORGANIZATION
SERVICE
CONTRACT NUMBER(S)
EXPIRATION
LOCATION
TELEPHONE NUMBER
EMAIL ADDRESS
LAST NAME, FIRST NAME, MIDDLE INITIAL
LAST 4 OF SSN
GRADE
RANK
SIGNATURE
INITIALS
DOD COMPONENT/ORGANIZATION
SERVICE
CONTRACT NUMBER(S)
EXPIRATION
LOCATION
TELEPHONE NUMBER
EMAIL ADDRESS
LAST NAME, FIRST NAME, MIDDLE INITIAL
LAST 4 OF SSN
GRADE
RANK
SIGNATURE
INITIALS
DOD COMPONENT/ORGANIZATION
SERVICE
CONTRACT NUMBER(S)
EXPIRATION
LOCATION
TELEPHONE NUMBER
EMAIL ADDRESS
Enclosure 11 - ASG-KU DES Form 190-16.04_Delegation of Authority (17 Jul 2016)
File details come from the government source that posted it. Updated .