Sponsorship_form.pdf

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Laundry Service
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W911S2-19-U-6007
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APPLICATION FOR SPONSORSHIP

PRIVACY ACT STATEMENT: The information you provide is covered by the Privacy Act of 1974, Title 5, U.S.C. 552a.

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

PRINCIPAL PURPOSE(S): To record personal data and vehicle information to ensure positive identification of personnel authorized access to the installation/restricted areas; to conduct criminal background checks through local and national law enforcement databases; to maintain accountability for issuance and disposition of access passes.

ROUTINE USES: The DoD Blanket Routine Use set forth at the beginning of the Army's compilation of systems of records notices may apply to this system.

DISCLOSURE: Voluntary. However, failure to provide the requested information will result in denial of access to the installation.

Request sponsorship for the following individuals:

Last Name

First Name

Middle Initial

Date of Birth

ID Type

ID Number

ID State

Vehicle Make

Vehicle Color

Vehicle Plate

State

Relationship

Justification: ________________________________________________________________________________________________

DATE OF REQUESTED ACCESS (MM/DD/YYYY) TIME OF REQUESTED ACCESS

FROM TO FROM TO

DAYS REQUESTED ACCESS MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

SPONSOR’S INFORMATION:

LAST NAME: FIRST NAME: MI: _

RANK/GRADE: _ ORGANIZATION: TELE:

ADDRESS: EMAIL:

I acknowledge as a Sponsor I am responsible for the conduct of my guests during their visit on Fort Drum.

(Sponsor’s Signature) Date

SECTION BELOW IS FOR USE BY INSTALLATION ACCESS CONTROL OFFICE

NCIC DATE: APPROVED/DISAPPROVED (circle one) CONTROL #

Approving Official Printed Name Approving Official Signature

IMDR-ES FORM 2, DEC 2014

Justification 1:
Justification 2:
LAST NAME:
FIRST NAME:
MI:
RANKGRADE:
ORGANIZATION:
TELE:
ADDRESS:
EMAIL:
Date:
NCIC DATE:
CONTROL:
Approving Official Printed Name:
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