Access Control Request Form - Letterkenny.pdf

LETTERKENNY ARMY DEPOT ACCESS CONTROL APPLICATION

Information on this form will be used to facilitate the completion of a National Crime Information Center (NCIC) III criminal background check IAW AR 190‐13.

Applicant Name: Maiden:

SSN#: DOB: POB:

Height: Weight: Sex: Race: Eyes: Hair:

Home Address:

Email Address

License: State Number Is your license currently under suspension? Yes No

Date of Visit: Purpose of Visit:

Sponsor’s Name: Agency:

Address: 1 Overcash Avenue, ATTN: AMLD‐ , Chambersburg, PA 17201 Telephone: 717‐267‐

I have read and have verified to the best of my ability that all of the information listed above is correct.

I understand that providing false or incorrect information on this form may affect my eligibility for access to the installation.

Applicant Signature:______________________________________________ Date: ________________________

LAW ENFORCEMENT USE ONLY

( ) No adverse information found, Installation Access is cleared by this office.

( ) Adverse information found, Access Control is cleared by this office. Escort required.

( ) Adverse information found, Installation Access is NOT cleared by this office.

Government Official Signature _____________________________________________ Date _______________________

AUTHORITY: 10 U.S.C. Section 3013, Secretary of the Army; AR 600‐20, Army Command Policy and E.O. 9397 (SSN). DoD Directive (DoDD) 5200.27 and the authority in DoDD 5106.01.PRINCIPAL PURPOSE(s): Prescribes procedures for DoD law enforcement activities (LEAs) to request, collect, maintain, use, and disseminate personally identifiable information (PII) and law enforcement information from person(s) during routine security and law enforcement functions (e.g., crime prevention, force protection, and criminal investigations). ROUTINE USE(S): DoD LEAs may collect, use, maintain, and disseminate PII and law enforcement information in compliance with section 552a of title 5, United States Code (also known as “The Privacy Act of 1974”), implemented in the DoD by DoDD 5400.11 and DoD 5400.11‐R.

DISCLOSURE: Voluntary. However, failure to provide all the requested information could lead to delay or rejection of entry onto the installation, or delay in completion or processing of requested or required documents for inadequate data.

PRIVACY ACT STATEMENT