W911SA21B2007 Attachment 10 FHL Form 7.pdf

Fort Hunter Liggett (FHL)

THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974

Section 1. Personal Information (Failure to Provide ALL Information May result in Denied Access)

2. Date of Birth (MM/DD/YYYY):1. Name (As it appears on ID) Last Name: First Name: FULL Middle Name:

Authority: Public Law110-181, The 2008 National Defense Authorization Act, Section109.

Principal Purpose: Provide necessary information to determine if applicant meets the installation access requirements in accodrdance with the U.S. Army Garrison, Fort Hunter Liggett Command Policy # 10-

9, Installation Access Procedures for Visitors. Use of Date of Birth, Driver License Number and Social Security Number (SSN) are necessary for positive identification of the applicant in the Department of

Justice database.

Routine Use: National Crime Information Center Interstate Identification Index (NCIC-III) criminal history check using the Department of Justice database.

Disclosure is Voluntary: Disclosure of SSN and other information is voluntary. However, applicant's failure to provide requested information will result in a delay or denial of installation access.

See Page 2 for important information concerning this form.

General Access Request Form

Information collected in this form is FOR OFFICIAL USE ONLY. Sponsors will collect the required applicant information individually and not provide appllicant access to each other's protected personal information.

State: Country:

12. Country of Citizenship (If not U.S answer block 14):

11. Place of Birth: City:

13. Passport Number: 14. List Immigration Document (Doc #, Type of Doc and Expiration Date):

17. Company Working For: 18. Company Address (Include City, State, Zip Code): 19. Company Phone Number:

16. Home Phone Number:Zip Code:State:City:15. Current Address: House Number & Street:

Section 2. Government Sponsor or Contract Representative - Authorizing Information

Section 3. Approval or Denial (To Be Completed by DES Personnel Only)

The Government Sponsor must complete their portion before it is accepted at the Visitor Control Center. The Government Sponsor has overall responsibility for the conduct of the pass holder at all times while they are on the Installation. Upon termination of contract, employee termination, or expiration of the access credential the Sponsor will retrieve the credential from the contractor/visitor and return it to the Visitor Control Center.

The sponsor will also make sure that Section 1 of this form is completely filled out and accurate.

7. Sponsor's Signature: 8. Date Signed:

9. Dates of Visit (From Date - Departure Date): 10. Special Hours (Normal Hours Mon - Fri, 0600-1800):

11. Purpose of Visit:

1. Name (Last, First, Middle): 2. Official Title 3. Organization (Directorate): 4. Work Phone Number:

5. Official Email Address 6. Contract Number

3. Driver's License/ID Number State Issued From: 10. Weight:9. Height:8. Hair Color:7. Eye Color:6. Race:5. Sex:4. Social Security Number (SSN):

FHL Form 7, February 2020 Page 1 of 2PREVIOUS EDITION IS OBSOLETE

Signature of Person Vetting: Date:

CLETS Message Number: FBI Number:

Access Granted Access Denied Time:Print Name of Person Vetting:

Acceptable Documents for Verification of Identity:

(You must provide a copy of one of the below listed documents with your Access Request)

State Issued Real ID Compliant Driver’s License or ID Card US or Foreign Passport or Passport Card

Border Crossing Card (Form DSP-150) Department of Homeland Security “Trusted Traveler” Cards

Veteran’s Health ID Card issued by the U.S. Dept. of Veterans Affairs U.S. Permanent Resident Card (Form I-551)

Certificate of Naturalization (Form N-550 or N-570) Transportation Worker Identification Credential (TWIC)

Additional Documents: If operating a vehicle you must present a valid Driver’s License, current vehicle registration and proof of valid insurance upon arriving at the Visitor Control Center for your pass.

1. I understand the information on this form is being collected in accordance with 50 U.S.C., Section 797, and DoD 5200.8, and federal laws permitting the installation commander to limit access to the installation for security reasons. I have voluntarily completed this form and shall provide the Army a specimen of my fingerprints. The information I have provided on this application is true, complete, and correct to the best of my knowledge and believe, and is provided in good faith. I understand that a knowing and willfully false statement on this application can be punished by fine or imprisonment or both (18 U.S.C. Section 1001).

2. The purpose for requesting information is to assist Access Control personnel in documenting visitor’s suitability for access to Fort Hunter Liggett. Social Security Number and date of birth are necessary to identify the person and records. This information may be used to determine suitability of person desiring access to Fort Hunter Liggett; as well as; for lawful purposes including law enforcement and litigation. This information will be used to generate state and federal criminal history records checks.

3. Persons who do not pass the security vetting will be denied unescorted access and provided with the process for submitting an appeal. The appeal process is governed by Army Directive 2014-05 and is non-waiver able.

4. Any conduct which is detrimental to the maintenance of good order and discipline aboard Fort Hunter Liggett may result in confiscation of the visitor pass/badge.

5. Pass holders will confine themselves only to those areas related to issuance of the pass. Pass holders will not enter any marked restricted and/or controlled areas.

6. Vehicles and packages may be inspected at any time during a Random Antiterrorism Measures (RAM) while aboard the installation.

7. Any firearm brought onto Fort Hunter Liggett for legitimate activity is required to be registered with the Directorate of Emergency Services (DES).

8. Concealed weapons permits are not valid on any Federal Installation.

There is also a new email established for people to send their questions and forms to:

usarmy.hunterliggett.id-readiness.mbx.des-vcc@mail.mil