ASG-KU_DES_Form_190_Application_(17_Jul_2016).xlsx

Sheet1

PRINCIPAL PURPOSE(S): The records support DoD physical security and information assurance programs, to issue individual facility/installation access credentials, and for identity verification purposes. The system also is used to record personal vehicles and property registered with the DoD and for producing facility management reports. The records may be accessed by other physical access control systems for further verification at other sites. Records may also be used for law enforcement purposes.

ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act of 1974, these records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a (b) (3) as follows: Under DoD Blanket Routine Use #1. For law enforcement purposes to …federal, state, local, or foreign (law enforcement agencies), charged with enforcing or implementing the statute, rule, regulation, or order issued pursuant thereto. The DoD 'Blanket Routine Uses' set forth at the beginning of the OSD compilation of systems of records notices apply to this system.

DISCLOSURE REQUIREMENT – THIS INFORMATION IS VOLUNTARY: Voluntary. However, failure to provide the requested information may result in denial of a DBIDS card or visitor’s pass and denial of entry to DoD installations and/or facilities.

CONDITIONS APPLICABLE ON RECEIPT: I understand that the ASG-KU Installation Access (IA) Card is valid only through the expiration date indicated. Exceptions may require additional screening, interview and background checks. It should also be known that any derogatory information returned from the applicant's background investigation or failure to comply with screening/interview requirements may reflect adversely on consideration for access and may result in barment proceedings being initiated. Its intended use and authorizations are limited to those indicated on this form and the card. I understand that the ASG-KU IA Card is US Government property, that it is not transferable, that it is not to be altered in any way, and that it must be surrendered upon request of the US Government, its designated representative, or the issuing agency. I understand that while on any ASG-KU Installation my person, possessions, vehicle and work area are subject to search at the discretion of the US Government or its designated representative. I understand that I am liable for the cost of replacement for my IA Card if lost. Any falsification on this form will result in immediate revocation of access privileges.

2. First Name (Given Name) 14. Citizenship: If dual citizen list both countries 15. Race

3. Middle Name/Suffix: 16. Address (Building Name/Number, Street Name/Number, etc):

4. Passport Number: Expiration Date (dd/mmm/yy): 17. Address Type:

5. Foreign Identification Number: Expiration Date (dd/mmm/yy): 18. City, State, Zip code: 19. Country

6. Date of Birth (dd/mmm/yy): 7. Height (inches): 8. Weight (pounds): 20. Home Phone Number: 21. Mobile Phone Number:

9. Gender: 10. Eye Color: 11. Hair Color: 22. Work Phone Number: 23. DSN Phone Number:

41. Subcontract #: 42. Subcontract (POC):

46. AA Unit Organization: 47. AA Work Number: 48. AA Mobile Number:

49. AA Email Address: 50. AA Signature and Date:

1. All persons, their personal property, US Government property, and vehicles may be searched on entry, while within the confines of, or when leaving US Forces installations. Persons attempting to gain entry, who refuse to identify themselves, provide digitized fingerprint minutia data (DFMD), hand geometry scan, or consent to search, will be denied access.

2. If I am authorized escort privileges, I understand that I am agreeing to monitor that person’s actions at all times, and I accept full responsibility for that person’s conduct while on the installation.

3. IA Cards are US Government property. Any Military Police Officer, Law Enforcement, Security Force or Access Control personnel may confiscate an IA Card that has expired, is being used fraudulently, and is being presented by a person other than the person to whom it was issued, or is obviously altered, damaged, mutilated or photocopied.

4. I must surrender my pass when

a. It is replaced (except when lost or stolen).

b. I no longer require access.

c. My sponsor or status changes.

d. I resign, am terminated, or am no longer officially sponsored.

5. If I lose my IA Card or if it is stolen, I must immediately notify either the Law Enforcement Station or Installation Access Office. Failure to do so is grounds for denying a replacement card.

6. Violations of ASG-KU security policies may be grounds for denying access to US Forces Installations and lead to confiscation of all installation access documents.

I acknowledge by my signature that I have read and understand the policy, requirements, and responsibilities above.

57. (Print/Type) Last, First, Middle Initial: 58. Signature: 59. Date (dd/mmm/yy):

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&"Arial,Bold"&9Enclosure 1 - ASG-KU DES FORM 190-16.01-Access Application (17 Jul 2016)

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71. Supporting Documents Enclosed (if applicable)

Organization Address Home Address Company Address Office Address Male Female

TDY

Escort Request New Registration Renew Registration Upgrade of Privileges Lost/Stolen IA Card Buehring Arifjan KNB/Patriot

SPOD

Charlie Delta w/Enc 6 Yes No Charlie Delta w/Enc 2C Buehring Arifjan KNB Patriot

SPOD

CAT 1 - OCN

CAT 2 - Foreign Military CAT 3 - US Contractor CAT 4 - US Government CAT 5 - Commander's Exception Approved Rejected Routed to DES Yes No Delta w/Enc 6 Yes No Yes No Delta w/Enc 2C OCN w/Enc 7 and 10