TE_03_PTA_InstallationAccessPassForm.pdf

Sex: M (___) / F (___)

Date of Birth: Eye Color: Hair Color: Height: Weight:

Home Phone:

Start: End:

Zip Code (DD MM YYYY) (DD MM YYYY)

Rank / Grade: Duty Phone:

Cell Phone:

Sponsor's Signature: Date:

Applicants Organization::

Aplicants POC:

POC's Signature: Date:

IAP Manager Signature: Date:

Comments:

Applicant Signature: Date:

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AUTHORIZATION: HOMELAND SECURITY PRESIDENTIAL DIRECTIVE 12 AND ARMY REGULATION 190-13 REQUIRES THAT ANY PERSON NOT POSSESSING A

GOVERNMENT ISSUED IDENTIFICATION AND WISHING TO BE GRANTED ACCESS TO A FEDERAL FACILITY BE VETTED USING THE NATIONAL CRIME

INFORMATION CENTER (NCIC). The following issues will prevent access to USAG-HI installations: Current Arrest Warrant, Currently Barred from entry to Federal

Installations, Any felonies within the last 10 years, Registered Sex Offenders, Crimes encompassing Sexual Assault, Armed Robbery, Rape, Child Molestation, production or possession of Child Pornography, Trafficking in Humans, Drug Possession with intent to sell or Drug Distribution, Espionage, Sabotage, Treason, Terrorism, Murder, Firearms/Explosive violation, or Acts or Activities designed to overthrow the U.S. Government by force. USAG-P can add further disqualifying factors that would deny an individual access onto the installations.

Duration of Pass:

City/State/Country of Birth:

Relationship to Sponsor:

STATEMENT OF UNDERSTANDING: I UNDERSTAND THAT AS THE SPONSOR, I AM RESPONSIBLE FOR THE ACTIONS OF THE ABOVE NAMED INDIVIDUAL.

REPORTS OF MISCONDUCT MAY BE CAUSE FOR IMMEDIATE TERMINATION OF THIS AUTHORIZATION. I ALSO UNDERSTAND THAT IF THE PASS IS NO

LONGER NEEDED AND HAS NOT EXPIRED, I WILL RETRIEVE THE PASS AND TURN IT OVER TO THE INSTALLATION ACCESS PASS OFFICE.

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Phone:

Sponsor Name:

IP

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Sponsoring Individuals Information:

IAP Manager Name:

POC Email:

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Routine Use: Information provided may be used to determine suitability of applicants desiring access on to U.S. Army Garrison, Pōhakuloa Installations as well as for other lawful purposes including law enforcement and litigation. For other official purposes, information on this form may be provided to other law enforcement agencies.

Disclosure: Submitting requested information is voluntary, however failure to provide information will result in access privileges being refused or withdrawn. The

Privacy Act Statement will apply throughout the duration of the Installation Access Pass.

Principal Purpose: The purpose for requesting personal information is to assist civilian access on to U.S. Army Garrison, Pōhakuloa Installations.

PRIVACY ACT INFORMATION

Authority: Title 10, United States Code, Section 2012

STATEMENT OF UNDERSTANDING: BY SIGNING THIS APPLICATION FOR AN INSTALLATION ACCESS PASS ID CARD, I AGREE TO ABIDE BY ARMY REGULATIONS

WHILE ON U.S. ARMY GARRISON, HAWAII INSTALLATIONS. I CERTIFY THAT ALL INFORMATION PROVIDED ON THIS FORM IS TRUE AND CORRECT.

City

USAG-P INSTALLATION ACCESS PASS APPLICATION

Applicant Information:

IAP Phone: (808)969-2429TO: USAG-P, Law Enforcement Office

House Number / Street Name / Apt. Number

Home Address:

C o m m a n d

A p p ro v a l

Sponsor Organization:

Request the following individual be authorized

U.S. Army Garrison Pōhakuloa Installation Access Pass

Applicant Name: SSN :

DAILY ACCESS PASS

SHORT TERM PASS

LONG TERM PASS

No Dergitory Info

"Cleared"

Dergitory Info

"Flagged"

NOT Applicable

Check All That Apply:

NCIC Check By:__________________________ Authenticated By:_________________________

APPROVED

DENIED

RETURNED

Name (Last, First, MI.):_____________________

Signature:_________________________

JULY 2008

eric.moller Typewritten Text

Mona Jean Black eric.moller Typewritten Text 808-694-0480 eric.moller Typewritten Text

USAG-HI DPW

eric.moller Typewritten Text 808-694-0480

Technical Exhibit #3 - PTA Installation Access Pass Form