Contractor__Vendor_Request_ACCESS_FORM.pdf

DEPARTMENT OF THE ARMY

U.S. ARMY HEALTH CONTRACTING ACTIVITY (Provisional)

REGIONAL HEALTH CONTRACTING OFFICE-CENTRAL (Provisional)

3551 ROGER BROOKE DRIVE STE 1103

JBSA FORT SAM HOUSTON TX 78234-6200

REPLY TO

ATTENTION OF

MCAA-S DATE

MEMORANDUM FOR 502D SECURITY FORCES SQUADRON

2163 WILSON WAY

FORT SAM HOUSTON TX 78234-0039

ATTN: PASS & REGISTRATION OFFICE (S5B)

SUBJECT: Application for Contractor/Vendor Installation Access Credential (AIAC)

1. The following company/organization is providing either vendor’s service or holds a contract with our organization. The individual is required to enter Joint Base San Antonio, Fort Sam Houston in an official capacity on a regular basis. Request the issuance of an access credential.

Company/Organization Contract/Service Number Required Times/Days of Week Required Dates

Full Address of Company/Organization

2. The below listed individual understands that this is an identification credential, not a sponsoring credential and that it will not allow entry into any facilities other than the installation gates. Use of this credential is strictly for business purposes only. Individual also agrees to adhere to all vehicle regulations and guidelines set forth by AFI 31-204, Air Force Motor Vehicle Traffic Supervision, and those set by the installation commander.

3. Upon termination contract expatriation, employee termination, or expiration of the access credential, the holder agrees to return it to the host contractor, sponsor, or building 4179 (Registration Office) or any

Visitor Control Center.

Name of Credential Holder Date of Birth

SEE ATTACHED.

Home Address

Vehicle Make Vehicle Model Year Color

Plate # State DL Number State

Registration Office Use Only

Requesting Authority/Authorizing Official

NCIC

Printed Name

COPS/SFMIS

Signature

FBI TWL

DoD ID #

OFF INIT

Duty Phone

SUP INIT

Email

All requests must be submitted in person or via encrypted .mil email to usaf.jbsa.502-abw.list.502-sfs-fsh-visitor-control-center-owner@mail.mil NLT 5 working days prior to the start date.

"FOUO, This document contains information exempt from mandatory disclosure under the FOIA. Title 5 U.S.C. 552 (b) (6) applies. This document also contains personal information that is protected by the Privacy Act of 1974 and must be safeguarded from unauthorized disclosure."

mailto:to%20usaf.jbsa.502-abw.list.502-sfs-fsh-visitor-control-center-owner@mail.mil mailto:to%20usaf.jbsa.502-abw.list.502-sfs-fsh-visitor-control-center-owner@mail.mil

Application for Installation Access Credential (Spreadsheet)

Contract/Service Number Company/Organization Employment Start Date Employment End Date

Personal Information Driver’s License

Full Name (L, F, MI) DOB Number State