B.07.01 Installation Access Roster Request_DC-23-0008.pdf

Previous editions are obsolete. Page 1 of 2

INSTALLATION ACCESS ROSTER REQUEST

(AE Reg 190-16)

Data required by the Privacy Act of 1974 (For U.S. citizens) Authority: 5 USC 301, Departmental Regulations; 10 USC 113, Secretary of Defense, Note at Public Law (P.L.) 106-65; 10 USC 136, Under Secretary of Defense for Personnel and Readiness; 18 USC 1029, Fraud and Related Activity in Connection with Access Devices; 18 USC 1030, Fraud and Related Activity in Connection with Computers; 40 USC, Information Technology Management; 50 USC, Chapter 23, Internal Security; P.L. 103-398, Government Information Security Act; P.L. 100-235, Computer Security Act of 1987; P.L. 99-474, Computer Fraud and Abuse Act of 1986; Executive Order 9397, Numbering System for Federal Accounts Relating to Individual Persons.

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.

Instructions

● Access-roster requests must be securely submitted three (3) workdays before the date access is required. To protect Personal Identifiable Information (PII), send by encrypted email to the USAG IACS office, use the DoD Secure Access File Exchange (SAFE) site https://safe.apps.mil/ or hand carry the CAC signed roster to the IACS office.

● Contractors and vendors must submit a copy of their passport or European Union (EU) ID and, if required, a visa or work permit along with a copy of a current (less than 12 months old) Good Conduct Certificate (GCC) or their country's equivalent. A certified translation is required if the GCC is not in English, German, or Italian.

● In Germany, U.S.-based contractors in country for more than 4 days must submit a copy of an approved "BACO-90" (For more information visit: https://www.europeafrica.army.mil/ contractor/).

● Individuals may be placed on an access roster for up to 30 days.

● For large events (for example, conferences or training events), a separate spreadsheet containing the same information on page two may be submitted with the AE Form 190-16F.

● AE Regulation 190-16 provides additional information about access rosters.

Sponsor information Last name

First name

Date of birth (YYYYMMDD)

E-mail address

Work telephone number

Home or cell phone number

Unit or organization

Access roster information Effective date

(YYYYMMDD)

Expiration date

(YYYYMMDD)

Days of week access is required

Times of day access is required

Reason for access

Installation for which access is required

To be completed for contractors and vendors only Company name

Company e-mail address and telephone number

FPCON

(CAC registration)

Visitor sponsor privileges (CAC registration) Yes No

Copy of background check and work permit provided (if required) (non-U.S. citizen)

Yes No On file at IACS office

Germany — Copy of BACO-90 provided (U.S. citizen working for U.S. based company)

Yes No On file at IACS office https://safe.apps.mil/ https://www.europeafrica.army.mil/contractor/ https://www.europeafrica.army.mil/contractor/

List of personnel

Last name / Nachname First name / Vorname Nationality Nationalität

Date of birth Geburtsdatum

PIN/ID card number Reisepass/Ausweis Nummer

Vehicle type and plate number Kfz-Marke und -Kennzeichen

Sponsor's name and organization Date (YYYYMMDD) Signature

Previous editions are obsolete.

Page of Page of

INSTALLATION ACCESS ROSTER REQUEST

(AE Reg 190-16) Data required by the Privacy Act of 1974 (For U.S. citizens) Authority: 5 USC 301, Departmental Regulations; 10 USC 113, Secretary of Defense, Note at Public Law (P.L.) 106-65; 10 USC 136, Under Secretary of Defense for Personnel and Readiness; 18 USC 1029, Fraud and Related Activity in Connection with Access Devices; 18 USC 1030, Fraud and Related Activity in Connection with Computers; 40 USC, Information Technology Management; 50 USC, Chapter 23, Internal Security; P.L. 103-398, Government Information Security Act; P.L. 100-235, Computer Security Act of 1987; P.L. 99-474, Computer Fraud and Abuse Act of 1986; Executive Order 9397, Numbering System for Federal Accounts Relating to Individual Persons.

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.

Instructions

● Access-roster requests must be securely submitted three (3) workdays before the date access is required. To protect Personal Identifiable Information (PII), send by encrypted email to the USAG IACS office, use the DoD Secure Access File Exchange (SAFE) site https://safe.apps.mil/ or hand carry the CAC signed roster to the IACS office.

● Contractors and vendors must submit a copy of their passport or European Union (EU) ID and, if required, a visa or work permit along with a copy of a current (less than 12 months old) Good Conduct Certificate (GCC) or their country's equivalent. A certified translation is required if the GCC is not in English, German, or Italian.

● In Germany, U.S.-based contractors in country for more than 4 days must submit a copy of an approved "BACO-90" (For more information visit: https://www.europeafrica.army.mil/contractor/).

● Individuals may be placed on an access roster for up to 30 days.

● For large events (for example, conferences or training events), a separate spreadsheet containing the same information on page two may be submitted with the AE Form 190-16F.

● AE Regulation 190-16 provides additional information about access rosters.

Sponsor information Last name First name Date of birth (YYYYMMDD) E-mail address Work telephone number Home or cell phone number Unit or organization Access roster information Effective date

(YYYYMMDD)

Expiration date

(YYYYMMDD)

Days of week access is required Times of day access is required Reason for access Installation for which access is required To be completed for contractors and vendors only Company name Company e-mail address and telephone number

FPCON

(CAC registration) Visitor sponsor privileges (CAC registration) Yes No Copy of background check and work permit provided (if required) (non-U.S. citizen) Yes No On file at IACS office Germany — Copy of BACO-90 provided (U.S. citizen working for U.S. based company) Yes No On file at IACS office List of personnel Last name / Nachname First name / Vorname Nationality Nationalität Date of birth Geburtsdatum PIN/ID card number Reisepass/Ausweis Nummer Vehicle type and plate number Kfz-Marke und -Kennzeichen Sponsor's name and organization Date (YYYYMMDD) Signature 9.0.0.2.20120627.2.874785 AE Form 190-16F, May 2021 (LCD Vers. 01.00) Installation Access Roster Request Physical Security, Office of the Provost Marshal, Office of the Deputy Chief of Staff, G3, HQ USAREUR-AF (AEOP-PM-PS, mil 537-7427) JavaScript must be enabled to use this form JavaScript muss aktiviert sein, um dieses Formblatt zu verwenden Print Form E-mail Form Reset Form Prescribing Directive Go to page

CUI

(when filled in)

AE FORM 190-16F, MAY 21

Previous editions are obsolete.

LCD Vers. 01.00

Text Field

Print Form E-mail Form Reset Form Go to page

INSTALLATION ACCESS ROSTER REQUEST

(AE Reg 190-16)

Data required by the Privacy Act of 1974 (For U.S. citizens)

Authority: 5 USC 301, Departmental Regulations; 10 USC 113, Secretary of Defense, Note at Public Law (P.L.) 106-65; 10 USC 136, Under Secretary of Defense for Personnel and Readiness; 18 USC 1029, Fraud and Related Activity in Connection with Access Devices; 18 USC 1030, Fraud and Related Activity in Connection with Computers; 40 USC, Information Technology Management; 50 USC, Chapter 23, Internal Security; P.L. 103-398, Government Information Security Act; P.L. 100-235, Computer Security Act of 1987; P.L. 99-474, Computer Fraud and Abuse Act of 1986; Executive Order 9397, Numbering System for Federal Accounts Relating to Individual Persons.

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.

Instructions

● Access-roster requests must be securely submitted three (3) workdays before the date access is required. To protect Personal Identifiable Information (PII), send by encrypted email to the USAG IACS office, use the DoD Secure Access File Exchange (SAFE) site https://safe.apps.mil/ or hand carry the CAC signed roster to the IACS office.

● Contractors and vendors must submit a copy of their passport or European Union (EU) ID and, if required, a visa or work permit along with a copy of a current (less than 12 months old) Good Conduct Certificate (GCC) or their country's equivalent. A certified translation is required if the GCC is not in English, German, or Italian.

● In Germany, U.S.-based contractors in country for more than 4 days must submit a copy of an approved "BACO-90" (For more information visit: https://www.europeafrica.army.mil/contractor/).

● Individuals may be placed on an access roster for up to 30 days.

● For large events (for example, conferences or training events), a separate spreadsheet containing the same information on page two may be submitted with the AE Form 190-16F.

● AE Regulation 190-16 provides additional information about access rosters.

Sponsor information Last name First name

Date of birth (YYYYMMDD) E-mail address Work telephone number Home or cell phone number Unit or organization

Access roster information

Effective date

(YYYYMMDD)

Expiration date

(YYYYMMDD)

Days of week access is required Times of day access is required Reason for access Installation for which access is required

To be completed for contractors and vendors only Company name Company e-mail address and telephone number

FPCON

(CAC registration)

Visitor sponsor privileges

(CAC registration) Yes No Copy of background check and work permit provided (if required) (non-U.S. citizen) Yes No On file at IACS office Germany — Copy of BACO-90 provided (U.S. citizen working for U.S. based company) Yes No On file at IACS office

List of personnel

Last name / Nachname

First name / Vorname

Nationality

Nationalität

Date of birth

Geburtsdatum

PIN/ID card number

Reisepass/Ausweis Nummer

Vehicle type and plate number

Kfz-Marke und -Kennzeichen Sponsor's name and organization James C. Hood USACE, Central Europe Area Office

Date (YYYYMMDD) Signature

Go to page

Classification_P02_FIELD:

(when filled in) Form_NumberDate_FIELD:

Form_Version_FIELD:

LCD Vers. 01.00

Enter last name of sponsor (required field).:

Sponsor information.

Enter first name of sponsor (required field).:

Sponsor information.

Select from calendar or enter date of birth (YYYYMMDD) of sponsor (required field).:

Sponsor information.

Enter e-mail address of sponsor.:

Sponsor information.

Enter work telephone number of sponsor (required field).:

Sponsor information.

Enter home- or cell-phone number of sponsor.:

Sponsor information.

Enter unit or organization of sponsor (required field).:

Access roster information.

Select from calendar or enter effective date (YYYYMMDD) of access.:

Access roster information.

Select from calendar or enter expiration date (YYYYMMDD) of access.:

Access roster information.

Enter days of the week access is required.:

Access roster information.

Enter time of day access is required.:

Sponsor information.

Enter reason for access.:

Sponsor information.

Enter installation for which access is required.:

Contractors and vendors only.

Enter name of company.:

Contractors and vendors only.

Enter e-mail address and telephone number of company.:

Contractors only.

Force protection condition (FPCON) Bravo is the default. Sponsors must attach justification for FPCON Charlie or Delta to meet conditions of the performance work statement or task order.:

Contractors only.

Check if visitor sponsor privileges are to be granted. Sponsors are required to attach justification to be approved or disapproved by the USAG commander or a designated appointee (unchecked by default).:

Contractors only.

Check if visitor sponsor privileges are not to be granted (unchecked by default).:

Contractors and vendors only.

Check if copy of non-U.S. citizen background check and work permit is provided (if required) (unchecked by default).:

False Contractors and vendors only.

Check if copy of non-U.S. citizen background check and work permit is not provided (if required) (unchecked by default).:

Contractors and vendors only.

Check if copy of non-U.S. citizen background check and work permit is on file at the Installation Access Control System (IACS) office (if required) (unchecked by default).:

False Contractors and vendors only (Germany only for U.S. based companies).

Check if copy of BACO-90 for U.S. citizen, working for U.S. company, is provided (unchecked by default).:

False Contractors and vendors only (Germany only for U.S. based companies).

Check if copy of BACO-90 for U.S. citizen, working for U.S. company, is not provided (unchecked by default).:

Contractors and vendors only (Germany only for U.S. based companies).

Check if copy of BACO-90 for U.S. citizen, working for U.S. company, is on file at the Installation Access Control System (IACS) office (unchecked by default).:

False List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

List of personnel.

Enter last name. / Tragen Sie den Nachnamen ein.:

List of personnel.

Enter first name. / Tragen Sie den Vornamen ein.:

List of personnel.

Enter nationality. / Tragen Sie die Nationalität ein.:

List of personnel.

Select from calendar or enter date of birth (YYYYMMDD). / Wählen Sie aus dem Kalender oder trage Sie das Geburtsdatum ein (JJJJMMTT).:

List of personnel.

Enter PIN or ID card number. / Tragen Sie die Reisepass oder Ausweis Nummer ein.:

List of personnel.

Enter vehicle type and plate number. / Tragen Sie die KFZ Marke und Kennzeichen ein.:

Signature.

Accept default entry or enter name and organization of sponsor.:

James C. Hood USACE, Central Europe Area Office Signature.

Select from calendar or enter date of signature (YYYYMMDD).:

Enter your common access card (CAC) and click to digitally sign this form.: