W911SA-21-Q-3057 Attachment 7 Form 452 Installation Access Pass.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.

Fort McCoy Form 452 May 2021

AEM6.2 V 7.0

Page of Fort McCoy Form 452 February 2021 Obsolete Fort McCoy Installation Access Pass 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. 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 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 non 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. ***NCIC-III Check Date, PS Specialist and PS Specialist Signature for DES USE ONLY**** When complete submit to: usarmy.mccoy.id-readiness.mbx.des-physical-security-iacs-form@mail.mil Legal Name as Appears on Driver's License or State ID: Example: John Edward Doe 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 non Begin Date End Date Work Access Hours Work Area/ Visit Location Company Name Employees Position/ Event 11.0.0.20130303.1.892433.887364 280-4222

DHR ASD

Trudy L. Ward FMF452_Fort McCoy Installation Access Pass Request 20210212 20210212