UPDATED_Sponsor_Form.pdf

SPONSORED PASS

1. APPLICANT INFORMATION: *WRITE LEGIBLY*

LAST Name: ___________________________ FIRST Name: _________________________ MIDDLE Initial: _______

Social Security # (full SSN required): _________________________ Date of Birth: _____________ Sex: Male or Female

Driver's License # or State Identification # ___________________________________________ State: ______________

Destination on Fort Belvoir (address, bldg. # or name of bldg.) ______________________________________________

Email Address: _______________________________________ Telephone # ________________________________

Applicant Certification: I certify the information provided is true and accurate, and I am providing it with the purpose of receiving a ACCESS PASS to allow access onto Fort Belvoir. I understand that I am required to turn in or destroy the pass upon expiration or prior to expiration. If I fail to do so my access to Fort Belvoir can be denied for any and all future requests. I understand that I must give Fort Belvoir Visitor Control Center consent to an initial and periodic background screenings prior to and after the issuance of an installation access badge/pass. Failure to do so will result in the termination of the application process. I further understand that these background screenings will determine my eligibility for access and continued access during the term of my request.

Applicant Signature Date

2. SPONSOR INFORMATION: Sponsor must work or live on Fort Belvoir. If sponsor works on Belvoir they must be U.S. Active

Duty Military or DoD Civilian CAC card holder. If sponsor lives on Belvoir they must be U.S. Active Duty or dependent ID card holder.

Last Name: __________________________________ First Name: _________________________________

Grade/Rank: ______________ DoD E-Mail Address (if Active Duty/DoD Civilian): _________________________________

Work On Installation: Organization/Unit: ___________________________ Organization/Unit Phone #: __________________

Live on Installation: Street Address: _____________________________ Phone # (for verification purposes) _______________

Requested pass duration (how long do you want the pass valid for, not to exceed 1 year) ____________________________

Sponsor Signature Date

SECTION BELOW IS FOR USE BY THE INSTALLATION ACCESS CONTROL OFFICE ONLY

6. ISSUING OFFICIAL: Approved / Disapproved

Issuing Official Signature Date of Approval

PRIVACY ACT ADVISEMENT: The information requested is for the purpose of granting access to the Fort Belvoir Installation. Providing requested information, to include your social security number (SSN), is voluntary. However, your access may not be granted if all requested information is not provided. AUTHORITIES: Executive Orders (EO) 10450, 10865, and 12333. The SSN, required for record accuracy, is requested pursuant to EO 9397.

All information that contains PII is protected as required.

SPONSOR’S CERTIFICATION: I certify that the applicant meets the justification requirements and that they require a PASS as indicated above in order to perform assigned duties, conduct official business or visit family/friends on Fort Belvoir. I understand my role as the sponsor and ensuring the PASS is retrieved upon expiration or prior to expiration if it is no longer required. If I fail to do so, my ability to be an approved sponsor can be removed.