VISITOR REQUEST FORM.pdf

VETTING CONSENT FORM

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 United States Code, Section 3013; DoDI 5200.08, Security of DoD Installations and Resources and the DoD Physical Security Review Board (PSRB), Army Regulation 190-13; The Army Physical Security Program.

PRINCIPLE PURPOSE: This form will be used to gather information that will be used to determine the fitness of an individual requiring physical access to Sierra Army Depot (SIAD). All unescorted persons entering a DoD installation must have a valid purpose to enter, have their identity verified and vetted, be issued, or in possession of, an authorized and valid access credential. Installation government representatives are required to query the National Crime Information Center (NCIC) database to vet the claimed identity of a visitor and to determine their fitness using biographical information including, but not limited to, the person's name, date of birth, and social security number.

ROUTINE USES: The information solicited on this form may be made available as a routine use to other government agencies and for law enforcement and administrative purposes to facilitate filing and retrieval.

DISCLOSURE: Information is voluntary. However, failure to furnish requested information may delay or result in the denial of access to SIAD.

INSTRUCTIONS: All visitors and contractors requiring physical access to Sierra Army Depot (SIAD) who are not in possession of a DoD identification card (e.g., CAC, DD Form 2, 2765, 1173's) Federal Personal Identity Verification (PIV) card, are required to complete this form to consent to vetting requirements. The applicant must complete all fields legibly and sign in ink. Applicant must be present to submit a valid, unexpired state or federal government-issued I.D.. The applicant must be present to claim the gate pass. Additional information on acceptable forms of identification can be found on Form I-9, Employment Eligibility Verification.

SECTION I. APPLICANT INFORMATION

2.FIRST NAME: 4.SUFFIX:

5.ALSO KNOWN AS (a.k.a.):

9.DRIVER'S LICENSE or STATE I.D. or PASSPORT

20. U.S. CITIZEN?

YES NO

23.PURPOSE OF VISIT:

18.COMPANY or ORGANIZATION NAME:

21.POINT OF CONTACT (POC) or SPONSOR AT SIAD:

SECTION II. APPLICANT STATEMENT OF UNDERSTANDING AND CERTIFICATION

I hereby authorize the Law Enforcement and Security Division to receive any criminal history/background information pertaining to me, which may be in the files of any Federal, State, or Local criminal justice agency or organization. I understand and agree that the information provided by me on this form will be used to conduct a criminal background check that will be used for the purpose of determining access to Sierra Army Depot (SIAD). I understand that access to SIAD may be revoked or denied at any time. I understand and agree that if the background check indicates that there is an outstanding warrant for my arrest then I will be detained and delivered to proper civil authority for execution of that warrant. I also understand that use of this form does not relieve me of any additional requirements by another organization or company to receive a criminal history background check. I certify that the information provided on this form is true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

I understand that false, fraudulent, or incomplete information herein may be grounds for the denial or revocation of access to the installation, and may be punishable by fine or imprisonment.

25.DATE (dd/MMM/yyyy): 26.APPLICANT SIGNATURE:

******************************************************************** OFFICE USE ONLY ***********************************************************************

NOTES:

DEPOT ACCESS: YES

VCO/NCIC OPERATOR:

SIAD FORM 1246; REV 2, JULY 2019

DENIED ESCORT

11.HEIGHT 12.WEIGHT(lbs) 13.EYE COLOR 14.HAIR COLOR

24.AREA TO BE VISITED:

1.LAST NAME:

22.POC PHONE NUMBER:

RESIDENT

17.BUSINESS PHONE:

3.MIDDLE NAME:

7.SOCIAL SECURITY NUMBER: 8.SEX:6.PLACE OF BIRTH (State or Country):

10.DATE OF BIRTH:

19.COMPANY PHONE NUMBER:

NO DRIVING

FOR OFFICIAL USE ONLY

PREVIOUS EDITIONS ARE OBSOLETE

FOR OFFICIAL USE ONLY

15.RESIDENTIAL ADDRESS (Street, City, State, Zip):

16.PHONE NUMBER:

STATE

DATE VETTED:

RRAD FORM 9025, APR 2017