Attachment_3-SATCOM_Camp_Roberts_Access_Request_Form_for_Site_Visit.pdf

SATCOM CAMP ROBERTS ACCESS REQUEST FORM

(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF

1974) ALL REQUESTS MUST BE SUBMITTED IN

TO THE VISITOR CONTROL CENTER OR PHYSICAL SECURITY OFFICE

ROUTINE VISITS AND OTHER

SPECIAL EVENTS (CHECK ONE)

CONTRACTOR/VENDOR ACCESS

Complete this form and return to your USASA-CR sponsor. A National Crime and Information Center (NCIC) check will be conducted prior to granting access to the installation.

By completing this application, you affirm/swear the information provided is true. That a knowing and willful false statement on this application can be punished by being barred from the installation, a fine, imprisonment or both. (18 U.S.C. Section 1001). Furthermore, that under the authority of 50 U.S.C. Section 797 and DoD 5200.8, the installation commander has imposed a continuing obligation for you to disclose. Questions may be directed to the Physical Security office at (805) 227-7625.

Section 1. PERSONAL INFORMATION (FAILURE TO PROVIDE ALL INFORMATION MAY RESULT IN DENIED ACCESS)

1. LAST 4. DRIVER’S LICENSE NUMBER 6. SOCIAL SECURITY NUMBER

14. HOME PHONE NUMBER

Section 2. PLACE OF BIR

1. CITY

5. U.S. CITIZEN? (If no, answer que

Section 3. CONTRACTO contract with our organization. Th The below listed individual unders gates. Use of this credential is stri Regulation and those set by the in

1. COMPANY / ORGANIZATION NA

Section 4. GOVERNMEN termination, or expiration of the a Government Sponsor must complete

7. SPONSOR'S ORGANIZATION

TH

SPONSOR’S SIGNATURE: ___

Section 5. WARNING: CO By accepting a visitor/contractor pa to reimburse the towing agent on b

Section 6: ATTESTATION

Should access be denied, you ma instructions on second page of the

Section 8. PRIVACY AC Authority: 50 USC Section 797; E.O.9397

PRINCIPAL PURPOSE(S): The purpose for reques records. This information may be used to determine checks.

INTENDED USE: For all personnel who are not aut

DISCLOSURE: Disclosure of requested informatio For Official Use Only (FOUO), This document co 1974 and must be safeguarded from unauthorize

Section 9. Approval or 1.

Access Granted

6. DATE REQUEST RECEIVED:

INSTALLATION ACCESS REQ

All previous editions are obsole

Initial Extend

Initial Renew

Section 7. Access Den

CREDENTIAL (CHECK ONE)

2. FIRST 3. MIDDLE

1. LAST 2. FIRS

5. DL STATE

7. DATE OF BIRTH (YYYYMMDD)

I understand the information on this access to the installation for securit shall provide the Army a specimen application is true, complete, and c be punished by fine or imprisonme

Date(s) of visit/contract term re

Purpose of visit:

16. CURRENT STREET ADDRESS15. WORK PHONE NUMBER

12. SEX 13. RACE8. EYE COLOR 9. HAIR COLOR 10. HEIGHT 11. WEIGHT

TH

2. STATE (If applicable) 3. COUNTRY stion 5) 6. LIST IMMIGRATION DOCUMENT TITLE, DOCUMENT NUMBER, AND EXPIRATION DATE (If applicable)

R/VENDOR INFORMATION (IF APPLICABLE) The following company/organization is providing either vendor’s service or holds a e individual is required to enter USASA-CR, CA in an official capacity on a regular basis. Request the issuance of an access credential.

tands that this is an identification credential, not a sponsoring credential and that it will not allow entry into any facilities other than the installation ctly for business purposes only. Individual agrees to adhere to all vehicle regulations and guidelines set forth by AR 190-5, Army Motor Vehicle stallation commander.

ME 2. FULL ADDRESS OF COMPANY / ORGANIZATION

T SPONSOR OR CONTRACT REPRESENTATIVE - AUTHORIZING INFORMATION Upon termination of contract, employee ccess credential the Authorizing Official will retrieve the credential from the contractor and return it to buildings 18021 ACP or Physical Security. The their portion before it is accepted at the Access Control Point. Being a sponsor you assume all responsibility for your visitor while they are on the installation.

6. SPONSOR'S OFFICIAL TITLE

8. SPONSOR'S CONTRACT NUMBER (Required if sponsoring a contractor)

E SPONSOR AGREES TO ACCEPT RESPONSIBILITY FOR THEIR VISITOR(S) WHILE ON THE INSTALLATION:

________________________________________________ DATE: _______________________________

NSENT TO SUBJECT SEARCH/SEIZURE, VEHICLE TOWING, REIMBURSEMENT, IMPOUNDMENT

ss you give your consent to search of your vehicle while it is entering on, or leaving USASA-CR. If your vehicle is towed or impounded, you agree ehalf of the vehicle owner/operator.

y request a denial wavier through the Directorate of Emergency Services-Physical Security Office the point of contact for denial wavier actions. Follow the wavier for submittal instructions, address, and documentation requirements.

T STATEMENT

ting personal information is to assist Access Control personnel in documenting visitors’ suitability for access to USASA-CR. Social security number and date of birth are necessary to identify the person and suitability of person desiring access to USASA-CR as well as, for lawful purposes including law enforcement and litigation. This information will be used to generate state and federal criminal history records horized a Common Access Card (CAC) or other federally authorized credential and require access to the installation for a special event and/or visit.

n is voluntary; however, failure to provided information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the special event and/or visit.

ntains information exempt from mandatory disclosure under the FOIA. Title 5 U.S.C. 552 (b) (6) applies. This document also contains personal information that is protected by the Privacy Act of d disclosure."

Denial (To be completed by DES Personnel) 2.

Access Denied

3. 4. 5.

Print Name Signature Date

7. DATE SPONSOR NOTIFIED OF APPROVAL/DISAPPROVAL:

UEST FORM, 02 January 2019.

te.

CLETS MSG#_____________________________ Page 1 of 2 ials

For Official Use Only (FOUO)

T 3. MIDDLE

18. STATE

3. CITY 4. STATE

9. CONTRACT EXPIRATION DATE

4. DATE OF BIRTH (YYYYMMDD) 5. SPONSER'S SSN

19. ZIP CODE

5. ZIP CODE

17. CITY

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 y reasons and that this data will be used to screen personnel who have or are seeking access to USASA-CR. I have voluntarily completed this form and of my fingerprints, if/when requested. I understand (a) criminal offense(s) may be prosecuted in federal court. The information I have provided on this orrect to the best of my knowledge and belief, and is provided in good faith. I understand that a knowing and willfully false statement on this application can nt or both (18 U.S.C section 1001).

quested: __________________________________________________ Date of Request:______________________________

TJC1024

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ACCEPTABLE DOCUMENTS FOR VERIFICATION OF IDENTITY/AUTHORIZATION TO WORK

ANY ONE OF THE DOCUMENTS BELOW:

ID card issued by a state or outlying possession of the United States provided it contains a photograph and information such as name, date of birth, gender, height, eye color, and address

US PASSPORT

CERTIFICATE OF NATURALIZATION (Form N-550 or N-570)

FOREIGN PASSPORT w/I-551 Stamp or Fm I-94 showing employment authorization

PERMANENT RESIDENT CARD or ALIEN REGISTRATION CARD

I-151 or I-551 (Must contain photographs)

ADDITIONAL DOCUMENT REQUIREMENTS:

SSN NUMBER

IF OPERATING A VEHICLE YOU MUST PRESENT A REAL ID ACT OF 2005 COMPLIANT VALID DRIVER

LICENSE, CURRENT REGISTRATION, AND PROOF OF VALID INSURANCE

NOTE:

1. ALL persons requesting a pass will be subject to vetting a records check through the National Crime Information Center (NCIC) Interstate Identification Index (III) is the minimum baseline background check for entrance onto Army Installations for non-CAC holders to include entrance of visitors and contractors. Vetting is to grant access and does grant the right to work, the government agent (COR) must coordinate with the anti-terrorism officer and the installation security manager for clearance for the contractors/vendors to perform services.

2. Persons who do not pass the security vetting will be denied access and provided with the process for submitting an appeal. The appeal process is governed by Army Directive 2014-05 and is non-waiverable. The appeal process can take an extended period of time.

3. Access Control Point or Physical Security staff may contact a Company POC listed on the access request form to verify that the request for a pass is valid.

4. All information on the access request form must be completed. The completed form and the verification documents listed above are to be presented to the Physical Security Office. Access request forms may be emailed to: astin.j.gill.mil@mail.mil and william.j.norton20.civ@mail.mil.

5. Any conduct which is detrimental to the maintenance of good order and discipline on the USASA-CR/ Camp Roberts Military Installation may result in confiscation of the visitor pass/badge, immediate removal from the installation, and the imposition of a BAR.

6. The Government Agent (sponsor) has overall responsibility for the conduct of the pass holder at all times while they are on the Installation. While this does not include punitive liability, the Agent may be required to brief senior installation leaders regarding acts of employee misconduct.

7. 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. Specifically airfields, command headquarters, motor pools, military training facilities, military barracks, housing areas other than those where you are an invited guest, areas where military weapons are present, fire stations, and communications facilities. Be prepared to identify yourself and the purpose of your presence on USASA-CR/Camp Roberts to police or security personnel at all times.

8. Vehicles and packages at any time while on the installation.

9. Firearms and other personal weapons are prohibited except for specific sporting activities.

10. Any firearm brought onto USASA-CR/Camp Roberts property for a legitimate activity is required to be registered with the Directorate of Emergency Services /Provost Marshal Office.

11. Concealed weapons permits are not valid on the installation.

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