Fort Carson Form 2036 March 2020.pdf

Please wait...

If this message is not eventually replaced by the proper contents of the document, your PDF viewer may not be able to display this type of document.

You can upgrade to the latest version of Adobe Reader for Windows®, Mac, or Linux® by visiting http://www.adobe.com/go/reader_download.

For more assistance with Adobe Reader visit http://www.adobe.com/go/acrreader.

Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries. Mac is a trademark of Apple Inc., registered in the United States and other countries. Linux is the registered trademark of Linus Torvalds in the U.S. and other countries.

FC FORM 2036-E, MAR 2020

REQUEST FOR A FORT CARSON INSTALLATION ACCESS CONTROL CARD

(Required for all Pass Requests greater than 24 hours) (Fort Carson Directorate of Emergency Services, Security and Access Control is the proponent agency for use of this form; IAW AR 190-13)

APPLICANT INFORMATION

GENDER:

REQUESTED CARD

BENEFICIARY INFORMATION

GOVERNMENT SPONSOR

I certify that the applicant meets the justification requirements as indicated above for access privileges. Furthermore I certify that the applicant requires frequent and repeated access as defined above in support of the beneficiary or 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.

SPONSOR'S NAME AND ORGANIZATION

PRINT CERTIFYING OFFICIAL'S NAME

PRINT CERTIFYING OFFICIAL'S NAME

RANK OR TITLE/PHONE NUMBER

RANK/PHONE NUMBER

RANK/PHONE NUMBER

SPONSOR'S SIGNATURE

CERTIFYING OFFICIAL'S SIGNATURE

CERTIFYING OFFICIAL'S SIGNATURE

INSTALLATION ACCESS CONTROL OFFICE USE ONLY

ISSUING OFFICIAL:

PRINT ISSUING OFFICIAL'S NAME

PRINT ISSUING OFFICIAL'S NAME

PRINT ISSUING OFFICIAL'S NAME

ISSUING OFFICIAL'S SIGNATURE

ISSUING OFFICIAL'S SIGNATURE

ISSUING OFFICIAL'S SIGNATURE

10.0.2.20120224.1.869952.867557