0_USAGJ 1529 CZ Site Visit - AC Repair for Server Rooms at B101.pdf

PageONE TIME/MULTIPLE ACCESS ROSTER

ESRV2.90PREVIOUS EDITIONS ARE OBSOLETE.USAGJ FORM 1529, DEC 2020

1. INSTRUCTION

DATE OF REQUEST

of Pages

A "One Time/Multiple Access Roster" is valid for a single group visit for a specific date and time. It is the sole responsibility of the individual sponsor to include all information listed. Processing time can be reduced if each sponsor will take the time to legibly list the required information in both English and Kanji. This roster must be submitted to the Pass office at Camp Zama, SHA or SGD or HB four (4) working days might no be processed in time.

Any request that is submitted or the same day will not be processed. Sponsor must sign guest in at the gate.

The sponsor's signature services as an acknowledgment the sponsor is aware of his/her individual responsibilities as the sponsor and to exercise total control over his/her non-SOFA guests in accordance with the provisions contained in USAGJ Regulation 190-13.

a.

b.

a. TYPED NAME (Last, First MI)

e. DESTINATION/INSTALLATION

h. MULTIPLE ACCESS

EFFECTIVE DATE

f. PURPOSE

i. MULTIPLE ACCESS

EXPIRATION DATE

k. SPONSOR'S SIGNATURE

g. TYPE OF REQUEST

d. TELEPHONE NO.b. RANK c. DUTY TELEPHONE NO.

a. VISIT DAY

NATIONALITY NAME (Last, First MI) ADDRESS VEHICLE

PLATE NO.

GATE NO.

d. TOTAL (VEHICLE)c. TOTAL (PERSONNEL)

FROM

b. VISIT TIME

TO

ONE TIME MULTIPLE

2. SPONSOR INFORMATION & ACCESS DESCRIPTION

3. VISITORS INFORMATION

e. AREA(S) TO BE AUTHORIZED

ZAMA SGD SHA YND APC PIER6 TORII

PASSPORT NO.

TEL

DRIVER'S LICENSE NO.

j. SPONSOR'S ORGANIZATION

SEX DATE OF BIRTH EYE COLOR HAIR COLOR HEIGHT WEIGHT

NATIONALITY NAME (Last, First MI) ADDRESS VEHICLE

PLATE NO.

PASSPORT NO.

TEL

DRIVER'S LICENSE NO.

SEX DATE OF BIRTH EYE COLOR HAIR COLOR HEIGHT WEIGHT

NATIONALITY NAME (Last, First MI) ADDRESS VEHICLE

PLATE NO.

PASSPORT NO.

TEL

DRIVER'S LICENSE NO.

SEX DATE OF BIRTH EYE COLOR HAIR COLOR HEIGHT WEIGHT

NATIONALITY NAME (Last, First MI) ADDRESS VEHICLE

PLATE NO.

PASSPORT NO.

TEL

DRIVER'S LICENSE NO.

SEX DATE OF BIRTH EYE COLOR HAIR COLOR HEIGHT WEIGHT

GATE NO.

GATE NO.

GATE NO.

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE:

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Title 10 U.S.C., Code, Section 3013.

To provide information to officials of the Army responsible for monitoring/controlling visitor's status.

Information is used to record and assign authorized pass numbers to allow authorized visitors onto U.S. Army installations.

Voluntary. Failure to disclose the required information will result in authorized pass numbers not being issued; therefore, causing the applicants to have to meet and escort on and off the installation their visitors.

V2.90

FMO

USAGJ FORM 1529

Mitsue-Miller, Yukiyo

ONE TIME/MULTIPLE ACCESS ROSTER

09 DEC 2020

DEC 2020

Page

ONE TIME/MULTIPLE ACCESS ROSTER

ESR

V2.90

PREVIOUS EDITIONS ARE OBSOLETE.

USAGJ FORM 1529, DEC 2020

1. INSTRUCTION

DATE OF REQUEST

of Pages A "One Time/Multiple Access Roster" is valid for a single group visit for a specific date and time. It is the sole responsibility of the individual sponsor to include all information listed. Processing time can be reduced if each sponsor will take the time to legibly list the required information in both English and Kanji. This roster must be submitted to the Pass office at Camp Zama, SHA or SGD or HB four (4) working days might no be processed in time.

Any request that is submitted or the same day will not be processed. Sponsor must sign guest in at the gate.

The sponsor's signature services as an acknowledgment the sponsor is aware of his/her individual responsibilities as the sponsor and to exercise total control over his/her non-SOFA guests in accordance with the provisions contained in USAGJ Regulation 190-13.

a.

b.

a. TYPED NAME (Last, First MI)

e. DESTINATION/INSTALLATION

h. MULTIPLE ACCESS EFFECTIVE DATE

f. PURPOSE

i. MULTIPLE ACCESS EXPIRATION DATE

k. SPONSOR'S SIGNATURE

g. TYPE OF REQUEST

d. TELEPHONE NO.

b. RANK

c. DUTY TELEPHONE NO.

a. VISIT DAY

NATIONALITY

NAME (Last, First MI)

ADDRESS

VEHICLE PLATE NO.

GATE NO.

d. TOTAL (VEHICLE)

c. TOTAL (PERSONNEL)

FROM

b. VISIT TIME

TO

2. SPONSOR INFORMATION & ACCESS DESCRIPTION

3. VISITORS INFORMATION

e. AREA(S) TO BE AUTHORIZED

PASSPORT NO.

TEL

DRIVER'S LICENSE NO.

j. SPONSOR'S ORGANIZATION

SEX

DATE OF BIRTH

EYE COLOR

HAIR COLOR

HEIGHT

WEIGHT

NATIONALITY

NAME (Last, First MI)

ADDRESS

VEHICLE PLATE NO.

PASSPORT NO.

TEL

DRIVER'S LICENSE NO.

SEX

DATE OF BIRTH

EYE COLOR

HAIR COLOR

HEIGHT

WEIGHT

NATIONALITY

NAME (Last, First MI)

ADDRESS

VEHICLE PLATE NO.

PASSPORT NO.

TEL

DRIVER'S LICENSE NO.

SEX

DATE OF BIRTH

EYE COLOR

HAIR COLOR

HEIGHT

WEIGHT

NATIONALITY

NAME (Last, First MI)

ADDRESS

VEHICLE PLATE NO.

PASSPORT NO.

TEL

DRIVER'S LICENSE NO.

SEX

DATE OF BIRTH

EYE COLOR

HAIR COLOR

HEIGHT

WEIGHT

GATE NO.

GATE NO.

GATE NO.

AUTHORITY: PRINCIPAL PURPOSE: ROUTINE USES: DISCLOSURE:

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Title 10 U.S.C., Code, Section 3013. To provide information to officials of the Army responsible for monitoring/controlling visitor's status. Information is used to record and assign authorized pass numbers to allow authorized visitors onto U.S. Army installations. Voluntary. Failure to disclose the required information will result in authorized pass numbers not being issued; therefore, causing the applicants to have to meet and escort on and off the installation their visitors.