W911SA-21-Q-3008 Attachment 3 FMF451_Fort McCoy Installation Access NCIC-III Check Request.pdf

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FORT McCOY FORM 451 FEBRUARY 2019 FOUO Fort McCoy Form June 2017 Obsolete Page of AEM6.2 v5.0 Fort McCoy Installation Access NCIC-III Check Request PRIVACY ACT STATEMENT AUTHORITY: The Privacy Act of 1974, Title 5 USC 552a. PRINCIPLE PURPOSE(S): To determine suitability of individual(s) requesting access to Fort McCoy. This information will be used to generate state and federal criminal history records checks. ROUTINE USE(S): Personal information may be disclosed to appropriate military and civilian emergency and investigation agencies to assist in determining suitability for access to Fort McCoy. DISCLOSURE: Voluntary; however failure to provide information will result in a refusal to grant access to Fort McCoy.

Legal Name as Appears on Driver's License or State ID. Example: John Edward Doe M 29-Apr-64 F123-4567-8912-54

WI

25-Jan-15 24-Jan-16

MON-FRI 0700-1700

Bldg 100 Commissary/TCI Example: Plumber/Bagger Last Name First Name Middle Name or NMN if none

SEX (M/F)

DOB

Drivers Licence Number Drivers License State Begin Date End Date Work Access Hours Work Area/ Visit Location Company Name Employees Position/Event Remarks Block (At a minimum include: purpose for access; contract number and expiration date) ** Note: If access is for contract purpose, Sponsor will be the COR. In all cases, Sponsor must be affiliated with Fort McCoy.

When complete submit to: usarmy.mccoy.imcom-central.list.des-physical-security@mail.mil Legal Name as Appears on Driver's License or State ID. Example: John Edward Doe M 29-Apr-64 F123-4567-8912-54

WI

25-Jan-15 24-Jan-16

MON-FRI 0700-1700 HOURS

Bldg 100 Commissary/TCI Example: Plumber/Bagger Last Name First Name Middle Name or NMN if none

SEX (M/F)

DOB

Drivers Licence Number Drivers License State Begin Date End Date Work Access Hours Work Area/ Visit Location Company Name Employees Position/Event Legal Name as Appears on Driver's License or State ID. Example: John Edward Doe M 29-Apr-64 F123-4567-8912-54

WI

25-Jan-15 24-Jan-16

MON-FRI 0700-1700 HOURS

Bldg 100 Commissary/TCI Example: Plumber/Bagger Last Name First Name Middle Name or NMN if none

SEX (M/F)

DOB

Drivers Licence Number Drivers License State Begin Date End Date Work Access Hours Work Area/ Visit Location Company Name Employees Position/Event Legal Name as Appears on Driver's License or State ID. Example: John Edward Doe M 29-Apr-64 F123-4567-8912-54

WI

25-Jan-15 24-Jan-16

MON-FRI 0700-1700 HOURS

Bldg 100 Commissary/TCI Example: Plumber/Bagger Last Name First Name Middle Name or NMN if none

SEX (M/F)

DOB

Drivers Licence Number Drivers License State Begin Date End Date Work Access Hours Work Area/ Visit Location Company Name Employees Position/Event Legal Name as Appears on Driver's License or State ID. Example: John Edward Doe M 29-Apr-64 F123-4567-8912-54

WI

25-Jan-15 24-Jan-16

MON-FRI 0700-1700 HOURS

Bldg 100 Commissary/TCI Example: Plumber/Bagger Last Name First Name Middle Name or NMN if none

SEX (M/F)

DOB

Drivers Licence Number Drivers License State Begin Date End Date Work Access Hours Work Area/ Visit Location Company Name Employees Position/Event 11.0.0.20130303.1.892433.887364 Trudy L. Ward 20170612

DHR-ASD

Fort McCoy Installation Access NCIC-III Check Request Trudy L. Ward Fort McCoy Form 451