Fort_Carson_Installation_Access_Control_Card_FC_Form_2036-E.pdf

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FC FORM 2036-E, DEC 2014

REQUEST FOR A FORT CARSON INSTALLATION ACCESS CONTROL CARD (Required for all Pass Requests greater than 24 hours) (DES is the proponent; the approving authority is DTM 09-012, December 8, 2009)

APPLICANT INFORMATION

GENDER (circle one): MALE / FEMALE

REQUESTED CARD

SPONSOR INFORMATION

BDE/BN CDR/XO/DIRECTOR/DEPUTY DIRECTOR/COR CERTIFICATION

I certify that the applicant meets the justification requirements as indicated in Paragraph 2 above for access privileges. Furthermore I certify that the applicant requires an access control card to perform assigned duties or conduct official business on Fort Carson.

Privacy Act Statement

Authority: 10 U.S.C. 3013, Secretary of the Army; Army Regulation 190-13, The Army Physical Security Program and E.O. 9397 (SSN).

Purpose(s): To support Department of the Army physical security and access control programs; Information Assurance program; to record personal data and vehicle information registered with the Department of the Army; to provide a record of security/access badges issued; to restrict entry to installations and activities; to ensure positive identification of personnel authorized access to restricted areas; to maintain accountability for issuance and disposition of security/access badges and for producing installation management reports.

Routine uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: The DoD 'Blanket Routine Uses' also apply to this system of records.

Disclosure: Disclosure of SSN and other personal information is voluntary; however, failure provide the requested information can result in denial of access to the military installation.

PRINT CERTIFYING OFFICIAL'S NAME

RANK/PHONE NUMBER

CERTIFYING OFFICIAL'S SIGNATURE

INSTALLATION ACCESS CONTROL OFFICE USE ONLY

ISSUING OFFICIAL: APPROVED / DISAPPROVED (circle one)

PRINT ISSUING OFFICIAL'S NAME

ISSUING OFFICIAL'S SIGNATURE

10.0.2.20120224.1.869952.867557