AFCENT_INSTALLATION_ACCESS_APPLICATION_16Dec2016.pdf

Renewal

Su M Tu W Th F Sa

USAFCENT INSTALLATION ACCESS APPLICATION

DATA REQUIRED BY THE PRIVACY ACT OF 1974

(Sections 3013,5013, and 8013. Title 10, United States Code, Executive Order 9397, and U.S.C. Section 552a)

Section 1- Access Information DBIDS Access Card: Escort Required Escort Privileges Vehicle Lane #

New Damaged NoLost Yes

FPCON

A B C DNo

Date of Birth Gregorian yyyy/mm/dd

Name:

Last, First Middle

Family Name:

Title/Position

Dates of Requested Access

Yes yyyy/mm/dd

Aliases:Nationality

Work Days From: From: (24hour time) To:

Work Hours Requested 24/7Installation Name(s)

Section 2 Personal Demographics

City /District of Birth

To:

Province / State of Birth

Country of Birth

AUTHORITY: DOD 5200.08R, AFI 31-101, CENTCOM OPORD 05-02, USAFCENTI 31-105 and Individual USAFCENT Installation Access Policies

PRINCIPAL PURPOSE: To establish positive identification of all personnel requiring access to USAFCENT Installations, including Host Nation Military and Civilian employees, Foreign National employees, and contractors supporting the U.S. Military mission at USAFCENT Installations. Also included are non-affiliated agencies and groups granted special installation access by the U.S. Government.

MANDATORY DISCLOSURE REQUIREMENT: Failure to provide the below requested information, including social security number, passport number, Host Nation Government Identification number, and/or Nation of Origin Identification Number, will result in the disapproval of this application. Disapproved applicants will be denied issue of an DBIDS Access Card (DAC) and access to USAFCENT controlled facilities. Personal information such as SSAN, Passport or Governmental Civil Identification provides an individual with a unique identification and will be handled as OFFICIAL USE ONLY in accordance with U.S. Federal Statutes.

CONDITIONS APPLICABLE ON RECEIPT: By virtue of signing this application and upon receipt of a DAC you understand the USAFCENT DAC is valid only through the expiration date indicated. Its intended use and authorizations are limited to those restrictions indicated on this form and the DAC. I understand that the USAFCENT DAC is a the property of the U.S Government, it is non-transferable, and if it is altered in any way access will be denied. It must be surrendered upon request of the U.S Government, its designated representative or the issuing agency. I understand that while on any USAFCENT Installation, my person, possessions, vehicle and work area are subject to search at the discretion of the U.S Government or its designated representative. I understand that I am liable for the cost of replacement for my DAC if lost.

Gender Male Female Unkwn Male Impersonator Female Impersonator

Married Single Race: White/Caucasian/Anglo Black

DivorcedMarital Status:

Height:

Unknown

Eye Color Age

Asian/Pacific Islander Birth

American Indian/Alaskan Separated Hair Color

Weight:

Birth y

Section 3 - Identifying Documentation and Contact Information

Number:

Travel Documentation Passport Foreign ID # Other

Paternal Grandmother's Name:

Father's Name: Paternal Grandfather's Name

USAFCENT Installation Access Application (IAA) Feb -2009

Project Name:

Employer/ Organization:

Employer Neighborhood:

Employer Country:

Military Branch:

Supervisor's Name Last, First, MI:

Contract Expiration Date:

Supervisor's Phone:

Employer City

Employer State/Provinc

Employer Street Addrs:

Section 4 -Contract Information

Mother's Name:

Issued by:

Telephone (Home):

Contract Number

Employer Phone Number:

Current Address

Other:

Cell Phone: Work Phone:

Previous Address (if less than a year at)

A pplicant's Last

N am e:

AUTHORITY: DOD 5200.08R, AFI 31-101, CENTCOM OPORD 05-02, USAFCENTI 31-105 and Individual USAFCENT Installation Access Policies

PRINCIPAL PURPOSE: To establish positive identification of all personnel requiring access to USAFCENT Installations, including Host Nation Military and Civilian employees, Foreign National employees, and contractors supporting the U.S. Military mission at USAFCENT Installations. Also included are non-affiliated agencies and groups granted special installation access by the U.S. Government.

MANDATORY DISCLOSURE REQUIREMENT: Failure to provide the below requested information, including social security number, passport number, Host Nation Government Identification number, and/or Nation of Origin Identification Number, will result in the disapproval of this application. Disapproved applicants will be denied issue of an DBIDS Access Card (DAC) and access to USAFCENT controlled facilities. Personal information such as SSAN, Passport or Governmental Civil Identification provides an individual with a unique identification and will be handled as OFFICIAL USE ONLY in accordance with U.S. Federal Statutes.

CONDITIONS APPLICABLE ON RECEIPT: By virtue of signing this application and upon receipt of a DAC you understand the USAFCENT DAC is valid only through the expiration date indicated. Its intended use and authorizations are limited to those restrictions indicated on this form and the DAC. I understand that the USAFCENT DAC is a the property of the U.S Government, it is non-transferable, and if it is altered in any way access will be denied. It must be surrendered upon request of the U.S Government, its designated representative or the issuing agency. I understand that while on any USAFCENT Installation, my person, possessions, vehicle and work area are subject to search at the discretion of the U.S Government or its designated representative. I understand that I am liable for the cost of replacement for my DAC if lost.

USAFCENT Installation Access Application (IAA) Feb -2009 Page 1 of 4

AUTHORITY: DOD 5200.08R, AFI 31-101, CENTCOM OPORD 05-02, USAFCENTI 31-105 and Individual USAFCENT Installation Access Policies

PRINCIPAL PURPOSE: To establish positive identification of all personnel requiring access to USAFCENT Installations, including Host Nation Military and Civilian employees, Foreign National employees, and contractors supporting the U.S. Military mission at USAFCENT Installations. Also included are non-affiliated agencies and groups granted special installation access by the U.S. Government.

MANDATORY DISCLOSURE REQUIREMENT: Failure to provide the below requested information, including social security number, passport number, Host Nation Government Identification number, and/or Nation of Origin Identification Number, will result in the disapproval of this application. Disapproved applicants will be denied issue of an DBIDS Access Card (DAC) and access to USAFCENT controlled facilities. Personal information such as SSAN, Passport or Governmental Civil Identification provides an individual with a unique identification and will be handled as OFFICIAL USE ONLY in accordance with U.S. Federal Statutes.

CONDITIONS APPLICABLE ON RECEIPT: By virtue of signing this application and upon receipt of a DAC you understand the USAFCENT DAC is valid only through the expiration date indicated. Its intended use and authorizations are limited to those restrictions indicated on this form and the DAC. I understand that the USAFCENT DAC is a the property of the U.S Government, it is non-transferable, and if it is altered in any way access will be denied. It must be surrendered upon request of the U.S Government, its designated representative or the issuing agency. I understand that while on any USAFCENT Installation, my person, possessions, vehicle and work area are subject to search at the discretion of the U.S Government or its designated representative. I understand that I am liable for the cost of replacement for my DAC if lost.