W911SA-22-Q-3130 Attachment 3 - Form 451.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 451 May 2021 FOUO Fort McCoy Form May 2021 Obsolete Page of AEM6.2 v10 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 DES PS Use Only Last Name First Name Middle Name or NMN if none

SEX (M/F)

DOB

Drivers License Number Drivers License State Begin Date End Date Work Access Hours Work Area/ Visit Location Company Name Clear/Denied/NMI (DES PS use only) 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.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 M 29-Apr-64 F123-4567-8912-54

WI

25-Jan-15 24-Jan-16

MON-FRI 0700-1700 HOURS

Bldg 100 Commissary/TCI DES PS Use Only Last Name First Name Middle Name or NMN if none

SEX (M/F)

DOB

Drivers License Number Drivers License State Begin Date End Date Work Access Hours Work Area/ Visit Location Company Name Clear/Denied/NMI (DES PS use only) 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