Vendor_Day_Pass.pdf

PREVIOUS EDITIONS ARE OBSOLETENTC FORM 40, OCT 2016

SECTION I -VISITOR/VENDOR INFORMATION

SECTION II -SPONSOR INFORMATION

5. CITY 6. STATE:

SECTION III - VALID FORMS OF IDENTIFICATION FOR INSTALLATION ACCESS VERFICATION

1. STATE ISSUED DRIVERS LICENSE (MN, MO, & WA are no longer valid ID's. Escort will be required.)*

2. STATE ISSUED CARD (MN, MO, & WA are no longer valid ID's. Escort will be required.)*

3. DA FORM 1602 (CIVILIAN IDENTIFICATION CARD AND GOLD STAR FAMILY)

4. VALID US PASSPORT OR PASSPORT CARD

5. TRANSPORTATION WORKER IDENTIFICATION CREDENTIAL (TWIC)

6. VALID FOREIGN PASSPORT WITH I-551 STAMP OR WITH INS FORM I-94 OR I-94A (Escort required.)

7. FORM I-766 WITH PHOTOGRAPH (EMPLOYMENT AUTHORIZATION DOCUMENT) (Escort required.)

* Drivers licenses/state-issued ID's from any state with the imprint `Enhanced Driver's License/Enhanced Identification Card' ARE valid forms of ID and holders do not require escort. Drivers licenses/state-issued ID's with the imprint `Not for Federal Identification' ARE NOT acceptable forms of ID and an escort will be required.

VENDOR'S DAY PASS (Visits of less than 24 hours) VISITOR'S TEMPORARY PASS APPLICATION (Visits up to 30 days)

FOR USE OF THIS FORM, SEE AR 190-13 AND NTC & FORT IRWIN POLICY LETTER #9. PROPONENT OF THIS FORM IS DES.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; Army Regulation 190-13, The Army Physical Security Program and E.O. 9397 (SSN), and HSPD-12.

PRINCIPLE PURPOSE: To support Department of the Army physical security and access control programs; Information Assurance program; to record personal data and vehicle information registered with the Department of the Army; to provide a record of security/access badges issued; to restrict entry to installations and activities; to ensure positive identification of personnel authorized access to restricted areas; to maintain accountability for issuance and disposition of security/access badges and for producing installation management reports.

ROUTINE USE: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3)and as follows: The DoD 'Blanket Routine Uses' also apply to this system of records.

DISCLOSURE: Voluntary. However, failure to provide requested information will result in the denial of an authorized access pass or equivalent and denial of entry to Army installations.

4. ADDRESS:

10. STATE OF ISSUE:8. DRIVER LICENSE #:

3. MI:2. FIRST NAME:1. LAST NAME:

15. PHONE (Home):13. PHONE (Cell):

12. DATE(s) OF VISIT(MM/DD/YYYY): FROM: TO:

SECTION IV - FOR OFFICE USE ONLY

Please email completed forms from a Department of Defense (DoD) Government email account ONLY to (usarmy.irwin.imcom.list.visitor-info-center-mbx-owners@mail.mil) at least 24 hours prior to arrival. Submittals from non-DoD accounts (e.g. personal, corporate, municipal etc.) will be rejected.

7. ZIP CODE:

11. COMPANY/ORGANIZATION(if Applicable):

9. STATE ID #::

TO:FROM:

14. PHONE (Work):

18. MI:17. FIRST NAME:16. LAST NAME: 19. RANK:

23. ZIP CODE:22. STATE:21. CITY:20. ADDRESS:

24. SPONSOR'S UNIT:

27. PHONE (Home):26. PHONE (Work):25. PHONE (Cell):

28. DATE OF NCIC III CHECK(MM/DD/YYYY): YES NO29. CLEAR FOR ACCESS: