Attachment_12_-_Request_for_Base_Access_-_SP_620_Project_16-B-0004_02_JUN_16.pdf

13. E-mail Address:

14. From (mm/dd/yyyy) To (mm/dd/yyyy) (Not to exceed 7 days)

15. Justification / Reason for Access: (include time and location)

4. Drivers License # 5. State 6. Gender 7. Height (Ft/in) 8. Weight 9. Eyes 10. Hair

DATA REQUIRED BY THE PRIVACY ACT OF 1974, TITLE 5, U.S.C. 552a AUTHORITY: Executive Orders (EO) 10450, 10865, 12333 and 9397. Department of the Army, Army Regulation (AR) 190-13 (Army Physical Security Program),25 Feb 2011.

PRINCIPAL PURPOSE(S): To provide adequate information in order to either grant or deny access to a Federal installation while maintaining effective law enforcement, force protection, and crime prevention programs.

ROUTINE USES: Information is furnished to criminal justice and law enforcement elements within the Department of Defense for investigation and prosecution when such cases fall within their jurisdiction or concurrent jurisdiction as applicable. The "Blanket Routine Uses" set forth at the beginning of the Army's compilation of systems of records notices also apply to this system.

DISCLOSURE: Mandatory. Information must be provided for all persons to be granted an Installation Access Pass. Failure to provide complete information on any individual(s) may result in denial of Installation Access Pass.

1. Last Name, First, MI 2. Social Security Number 3. Date of Birth (mm/dd/yyyy)

APPLICANT INFORMATION

REQUEST FOR FORT RILEY ACCESS BADGE

11. Company/Business/Address 12. Phone

By signing this document, I consent to have a National Crime Information Center Interstate Identification Index (NCIC III) conducted on me. I understand that this information is being used to determine my fitness to access the Fort Riley Military Installation and that no information, up to and including the outcome of the NCIC III check, will be furnished to me, my sponsor, or anyone else, at any time. I further understand that this request will allow the NCIC III check to be done, however, I must still appear in person at the Henry Visitor Control Center upon receipt of an email stating that the NCIC III check is completed.

Applicant Signature: __________________________________________ Date: _____________________

F M

OFFICE USE ONY - DO NOT COMPLETE BELOW T HIS LINE

Driver's License N/A Insurance N/A Debarment Roster

NCIC III: Wants / Warrants:

Approved Denied Negative Derogatory Information

SID/FBI #: Date:

TYPE OR PRINT FULL NAME SIGN DATE

FR Form 103-1 May 2015

13. E-mail Address:

14. From (mm/dd/yyyy) To (mm/dd/yyyy) (Not to exceed 7 days)

15. Justification / Reason for Access: (include time and location)

4. Drivers License # 5. State 6. Gender 7. Height (Ft/in) 8. Weight 9. Eyes 10. Hair DATA REQUIRED BY THE PRIVACY ACT OF 1974, TITLE 5, U.S.C. 552a AUTHORITY: Executive Orders (EO) 10450, 10865, 12333 and 9397. Department of the Army, Army Regulation (AR) 190-13 (Army Physical Security Program),25 Feb 2011.

PRINCIPAL PURPOSE(S): To provide adequate information in order to either grant or deny access to a Federal installation while maintaining effective law enforcement, force protection, and crime prevention programs.

ROUTINE USES: Information is furnished to criminal justice and law enforcement elements within the Department of Defense for investigation and prosecution when such cases fall within their jurisdiction or concurrent jurisdiction as applicable. The "Blanket Routine Uses" set forth at the beginning of the Army's compilation of systems of records notices also apply to this system.

DISCLOSURE: Mandatory. Information must be provided for all persons to be granted an Installation Access Pass. Failure to provide complete information on any individual(s) may result in denial of Installation Access Pass.

1. Last Name, First, MI 2. Social Security Number 3. Date of Birth (mm/dd/yyyy)

APPLICANT INFORMATION

REQUEST FOR FORT RILEY ACCESS BADGE

11. Company/Business/Address 12. Phone By signing this document, I consent to have a National Crime Information Center Interstate Identification Index (NCIC III) conducted on me. I understand that this information is being used to determine my fitness to access the Fort Riley Military Installation and that no information, up to and including the outcome of the NCIC III check, will be furnished to me, my sponsor, or anyone else, at any time. I further understand that this request will allow the NCIC III check to be done, however, I must still appear in person at the Henry Visitor Control Center upon receipt of an email stating that the NCIC III check is completed.

Applicant Signature: __________________________________________ Date: _____________________

OFFICE USE ONY - DO NOT COMPLETE BELOW T HIS LINE

NCIC III: Wants / Warrants:

SID/FBI #: Date:

TYPE OR PRINT FULL NAME SIGN DATE

FR Form 103-1 May 2015 10.0.2.20120224.1.869952.867557 785-239-3759 12/22/2014 DHR/ASD Forms Mgr T Jeffery Request for Fort Riley Installation Access Pass 1/1/2015