RFPAttach1LocalAgencyRecordCheck.pdf

FOR OFFICAL USE ONLY

FOR OFFICAL USE ONLY FHL Physical Security Branch

Local Agency Records Check/ Report Police Division, Emergency Services Center, Bldg 235, USAG Fort Hunter Liggett Ca 93928

Provided Information are Subject to the Privacy Act of 1974 The Privacy Act of 1974, 5 U.S.C. § 552a, Public Law No. 93-579, (Dec. 31,1974) establishes a Code of Fair Information Practice that governs the collection, maintenance, use, and dissemination of personally identifiable information about individuals that is maintained in systems of records by federal agencies. A system of records is a group of records under the control of an agency from which information is retrieved by the name of the individual or by some identifier assigned to the individual. The Privacy Act requires that agencies give the public notice of their systems of records by publication in the Federal Register. The Privacy Act prohibits the disclosure of information from a system of records absent the written consent of the subject individual, unless the disclosure is pursuant to one of twelve statutory exceptions. The Act also provides individuals with a means by which to seek access to an amendment of their records, and sets forth various agency record-keeping requirements.

*Checking the yes box in the consent column and initialing indicates that the individual has given consent to conduct the Local agency records check.

. 1.Purpose:

Installation Access Employment

2.Requesting Organization:

3.Date Submitted:

4.Date Record Check Concluded:

5. Name (Last, First)

(Maiden Name or other Names used)

*C onsent

G ender

R ace

C ategory

DOB

(mm-dd-yyyy)

Drivers License (&State)

SSN

(9digit)

POB

(City/State/ Country)

Record Check

(Results)

R eport# Clear Not

Clear 1.

YES

Initials

F

M

W B H O

CIV

FN

a.

Maiden Name or other Names used 2.

W B

3.

W B

4.

W B

5.

W B

Clear NO RECORD FOUND which may preclude assignment Not Clear A RECORD FOUND which may preclude assignment

“Local Civilian Police Records Check has been conducted in accordance with regulatory requirements.”

*Remarks

Chief of Police

(Signature)

Date:

LEONARD LOVETT, GS-12, 831-386-2884

shawn.reinhart Typewritten Text

ATTACHMENT 1

W9124J-12-R-0015

FOR OFFICAL USE ONLY

FOR OFFICAL USE ONLY FHL Physical Security Branch

United States Army Garrison Fort Hunter Liggett Physical Security Branch

Building 235, Blackhawk Street Fort Hunter Liggett, California 93928

Installation Access Roster (DTM 09-012, Change 1, September 30, 2010)

1. Request Access to:

Communication Site:

Cantonment Areas Training Areas:

Other:

Request Camera/ Image Data Recording or Written Recording

2. COR or Sponsor Information (DIR, Name, Phone &email)

3. Contractor Information (Name, Phone &email)

4. Date(s) of Contract Work or Visit From: To:

5. Purpose. (Provide Brief Statement of Work (SOW) / Brief description of Visit).

6. NAME

(Last, First)

SSN

(Last Four)

OCCUPATION CONTRACTOR

(Rep) (Sub-)

PHONE NUMBER

7. CONTRACTOR

Name

Title

Signature

Date

8. ON-SITE POC

(Sponsor/ Escort)

Name

Phone # & e-mail address

9. APPROVAL

LORI FASH

USAG Security Manager

Signature Date

SHYLON M. GREEN

USAG Physical Security Officer

Signature Date

FHL-AC Roster_311-rsa Access Control Requirements:

1. Present Access Roster to Security /Police or Range Control personnel upon request.

2. Restricted Area Requirement: Post approved Access Rosters within facilities.

Special Instructions:

1. Need of Assistance Contact the Physical Security Office (831) 386-3882 / 2526

2. Please Type or Print legibly and submit within 15 days of the event.

3. E-mail form to: usarmy.hunterliggett.imcom-central.list.fhl-physical-se@mail.mil within 15 days, unless additional information or further verification is required the approval process and access to the requested location should be concluded.

Recommend that the submitting agency contact this office or Emergency Service Dispatch for finial conformation.

4. Approved Access Rosters will be posted at vehicle registration, Emergency Services Dispatch, ACP and in the contractor position.

Recommend contractors maintain a copy. You must present a valid ID and be listed on the approved access roster to obtain temporary vehicle registration, visitor badges or Range Control Training Area passes, or sign and pick-up keys to facilities. Pick-up these items at Bldg# 235, ES Dispatch; Hours of Operation: 24 hrs/ 7 days a week.