Attachment_15._TE15_190-16A_Application_for_US_Forces_In_Europe_Installation_Pass.pdf

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AE FORM 190-16A, DEC 09

Previous editions are obsolete.

Vers. 01.00 Page of Page of

APPLICATION FOR U.S. FORCES IN EUROPE INSTALLATION PASS

(AE Reg 190-16) PRIVACY ACT STATEMENT (For U.S. Citizens)

Authority: 5 USC 301 Departmental regulations; 10 USC 113, Secretary of Defense, Note at Pub. L. 106-65; 10 USC 136, Under Secretary of Defense for Personnel and Readiness; 18 USC 1029, Access Device Fraud; 18 USC. 1030, Computer Fraud; 40 USC Information Technology Management; 50 USC, Chapter 23, Internal Security; Pub. L. 103-398, Government Information Security Act; Pub. L. 100-235, Computer Security Act of 1987; Pub. L. 99-474, Computer Fraud and Abuse Act; EO 9397 (SSN).

Principal purpose(s): To identify personnel authorized routine or recurring access to installations under U.S. control.

Routine use(s): Those permitted under 5 USC 522a(b) of the Privacy Act and as specifically allowed outside the DOD pursuant to 5 USC 522a(b)(3) of the Privacy Act.

Disclosure: Voluntary; however, failure to provide any item of information will result in denial of entry onto U.S.-controlled installations.

Please refer to the instructions on page 3 to ensure that the form is correctly filled in.

1. To

2. From

3. Date (YYYYMMDD)

4. Name (Last, first, MI)

5. Sponsor address

6. Address (Company, organization, unit)

7. Person category

8. Country of citizenship

9. Personal ID number

10. Supporting document expiration date (Passport/ID card)

11. Residence permit required?

Yes No

12. Work permit required?

Yes No

13. Type pass requested Installation pass Temporary installation pass

14. Date of birth

(YYYYMMDD)

15. Weight (Pounds)

16. Height (Inches)

17. Eye (Color)

18. Hair (Color)

19. Limitations/time/day access is required

20. Pass expiration date (YYYYMMDD)

IACO REGISTRAR MUST VALIDATE

21. FPCON restriction Justification

22. Installations for which access is required (Provide justification) Justification

23. Sign-in privileges No Yes (Provide justification) Justification

24. Privately owned vehicle (POV) registration information (Additional vehicles my be added on a separate sheet of paper)

a. License number

b. Country

c. Make

d. Model

e. Year

f. Body type

g. Color

25. Company name, telephone number, and e-mail

26. Required attachments (Check applicable boxes) All installation-pass applications must include supporting documents. Requirements may be different depending on the person category selected.

Residence Permit Work Permit Police Good Conduct Certificate (PGCC) (Polizeiliches Führungszeugnis) (no entries) PGCC (Entries adjudicated) Military Police (MP) check Fax-Back (U.S. contractor) Proof of AE Form 604-1A, Local National Screening Program (LNSP, initiation LNSP (No entries) LNSP (Entries adjudicated)

27. Verification by sponsoring official (must check both boxes) I have reviewed the results of all background checks required by AE Regulation 190-16 and verify that there is no derogatory information that would preclude the issuing of an installation pass.

I verify that the applicant has been informed about the purpose and proper use of the installation pass. I have reviewed AE Regulation 190-16 and believe this packet is administratively correct and fully and accurately indicates the applicant's access requirements. However, if there is a problem or you need further information, please contact me.

a. Organization, telephone number, and e-mail

b. Name and title

c. Signature (Digital or original)

d. Date (YYYYMMDD)

28. To be completed by the registrar

a. Registrar name (Printed)

b. IACS office

c. Registrar's signature

d. Date issued (YYYYMMDD)

29. Additional comments Instructions for completing AE Form 190-16A Block 1. To Enter the name of the servicing installation access control office.

Block 2. From Enter the name of the sponsoring official's organization.

Block 5. Sponsor address Enter the mailing address of the sponsoring organization. For the person categories Personal-Service Employee, Visitor (FM/Europe), and Visitor (not FM/Europe) also include the requester's mailing address.

Block 6. Address Enter the address of the unit assignment. This address will depend on the applicant's person category. For example, for local national employees, enter the hiring organization's address. For contractors and delivery personnel, enter the address of their company. Visitors should list their home mailing address.

Block 7. Person category » Contractor (EU/NATO) Contractor who is a resident of the European Union or a NATO-member country.

» Contractor (U.S.)

Contractor who is a U.S. citizen working for a U.S. company based in the United States.

» Delivery Personnel Personnel making recurring deliveries or providing similar service not asso-ciated with a Government contract.

» DOS/American Embassy Department of State and American Embassy personnel.

» Foreign Student Foreign student at the Marshall Center.

» Gate Guard » HN Government Host-nation Government official.

» HN Military Member Host-nation military member.

» Local National Employee » Member PO Member of a private organization.

» NATO Member » Official Guest » Personal-Service Employee » Vendor Vendor providing merchandise or services not associated with a Government contract.

» Visitor (FM/Europe) Immediate Family member living in Europe.

» Visitor (not FM/Europe) Friend or Family member not included in category above.

» Other Block 9. Personal ID number Enter the personal ID number or the passport number from the supporting document used. The applicant must have one of the following supportingdocuments:

• Passport • Personal ID card issued by the country of citizenship (for example, German Personalausweis, Belgian identity card, Italian carta d'identita

• Military ID card issued by one of the NATO Sending States (Belgium, Canada, France, the Netherlands, United Kingdom) Block 10. Supporting documentation expiration date Enter the expiration date of the supporting document (for example, expiration date of passport or German Personalausweis).

Block 11. Residence permit required?

If required, check the appropriate box to indicate whether a copy of the residence permit is attached. See AE Regulation 190-16 for guidance.

Block 12. Work permit required?

If required, check the appropriate box to indicate whether a copy of the work permit is attached. See AE Regulation 190-16 for guidance.

Block 13. Type pass requested Check the appropriate box. If an installation pass is desired, a temporary installation pass may be issued pending completion of a required background check. A temporary installation pass is valid for up to 90 days. The restrictions associated with each pass are different for each individual's access requirements.

Block 19. Limitations/time/day access is required Enter "24/7" if access is required all the time; otherwise state the specific days of the week and times. IACOs may require justification for liberal access (such as 24/7), so sponsoring organizations should be prepared to justify this entry.

Block 20. Pass expiration date This field will be validated by the IACO. Justification for this date must be provided. A temporary installation pass is valid for up to 90 days. The expiration date of an installation pass depends on the limitations of the person category (block 7) selected as well as the expiration date of the supporting document (for example, passport) that was used to obtain the installation pass. The expiration date will be whichever date is earlier.

Block 21. FPCON restriction Enter the FPCON restriction.

• Delta (provide justification, including first-responder duties) • Charlie (provide justification, including a list of essential duties) • Bravo Block 22. Installations for which access is required Sponsor must provide specific justification for applicant's access requirements in block 22. Access is limited to the minimum number of installations required for the applicant. Examples include Campbell Barracks or Taylor Barracks. If greater access is required (for example, USAG-wide, multiple USAGs, or access to an Air Force base or a Navy base), additional documentation is required, such as a contract statement of work that lists by name the installations and bases.

Block 23. Sign-in privileges Check the appropriate box to indicate whether sign-in privileges are required. If sign-in privileges are requested, the sponsoring official must include a written justification in block 23. The written justification must explain why the applicant requires sign-in privileges in the performance of duties. NATO Member and Department of State and American Embassy person categories are defaulted to sign-in privileges authorized; no justification is required.

Block 24. Privately owned vehicle (POV) registration information

a. State the license plate number exactly as it appears. b. State the country the license plate was issued for. c. State the make of the vehicle (for example, Opel, Saab, BMW). d. State the model of the vehicle (for example, 325I, Astra, 190E, S60). e. State the year of the vehicle (YYYY). f. State the body type of the vehicle (for example, 2-door sedan, bus). g. State the color of the vehicle.

Block 25. Company name, telephone number, and e-mail This block is applicable only for applicants in the Contractor (EU/NATO) person category. If applicable, enter name, telephone number, and e-mail of the company.

Block 26. Required attachments Check all applicable boxes and provide a photocopy of supporting documents.

Block 27. Verification by sponsoring official State the name, title, organization, telephone number, and e-mail of the sponsoring official. The IACO must have a copy of the designation of sponsoring officials memorandum from your organization identifying who is authorized to sign installation pass applications.

Block 29. Additional comments Provide any requested information/justification.

8.0.1291.1.339988.308172 AE Form 190-16A, Dec 09 (Vers. 01.00) Application for U.S. Forces in Europe Installation Pass USAREUR Provost Marshal (PM) (AEAPM-SO, DSN 381-7427) Go to Page

AE FORM 190-16A, DEC 09

Vers. 01.00 Go to Page

AE FORM 190-16A, DEC 09

Vers. 01.00

Unit 29351

APO AE 09014

Contractor who is a resident of the European Union or a NATO-member country.

» Contractor (U.S.)

Contractor who is a U.S. citizen working for a U.S. company based in the United States.

» Delivery Personnel Personnel making recurring deliveries or providing similar service not asso-ciated with a Government contract.

» DOS/American Embassy Department of State and American Embassy personnel.

» Foreign Student Foreign student at the Marshall Center.

» Gate Guard » HN Government Host-nation Government official.

Enter the mailing address of the sponsoring organization.: » HN Military Member Host-nation military member.

» Local National Employee » Member PO Member of a private organization.

» NATO Member » Official Guest » Personal-Service Employee » Vendor Vendor providing merchandise or services not associated with a Government contract.

» Visitor (FM/Europe) Immediate Family member living in Europe.

» Visitor (not FM/Europe) Friend or Family member not included in category above.

» Other