W911SA-22-Q-3130 Attachment 4 - Form 452.pdf

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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