ARW_Form_11_Visitor_Form.pdf

PDF 249 KB Posted Jun 29, 2018

Attached to: Mass Notification System (Klaxon) Federal contract opportunity
Solicitation number: W912J2-18-R-5011
Issued by: Department of the Army Wisconsin Army National Guard

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AUTHORITY: Privacy Act of 1974 (5 USC Section 522(A)(7)) 41 USC Section 423, 5CFS Section 2635.602, AR 340-21 Title 10 and 37 USC.

ROUTINE USE(S): To authorize access to DoD facilities. Information may be reported to federal, state, and local law enforcement agencies with jurisdictional interests.

DISCLOSURE: Voluntary. Failure to provide requested information will result in denial of access to DoD facilities.

√ LEGAL LAST NAME

FULL FIRST

NAME

FULL MIDDLE

NAME

DATE OF

BIRTH

ISSUING

STATE OF ID

MILITARY

ID √ RANK/NOTES:

Doe John Michael 5/5/1965 WI

Smith Jane Ann X Major

128th Air Refueling Wing - VISITOR ACCESS REQUEST

PRIVACY ACT STATEMENT

PRINCIPLE PURPOSE: To enable military security and/or law enforcement personnel to conduct citizenship and criminal background investigations for civilians requesting access to DoD facilities.

Date:

ARW Form 11, 27 Jan 2015

SUBJECT TO THE PRIVACY ACT OF 1974

Properly dispose of this document after use AUTHENTICATED BY (SFS E6 or Higher):_____________

AUTHORITY: Privacy Act of 1974 (5 USC Section 522(A)(7)) 41 USC Section 423, 5CFS Section 2635.602, AR 340-21 Title 10 and 37 USC.

ROUTINE USE(S): To authorize access to DoD facilities. Information may be reported to federal, state, and local law enforcement agencies with jurisdictional interests.

DISCLOSURE: Voluntary. Failure to provide requested information will result in denial of access to DoD facilities.

√ LEGAL LAST NAME

FULL FIRST

NAME

FULL MIDDLE

NAME

DATE OF

BIRTH

ISSUING

STATE OF ID

MILITARY

ID √ RANK/NOTES:

128th Air Refueling Wing - VISITOR ACCESS REQUEST

PRIVACY ACT STATEMENT

PRINCIPLE PURPOSE: To enable military security and/or law enforcement personnel to conduct citizenship and criminal background investigations for civilians requesting access to DoD facilities.

Date:

ARW Form 11, 27 Jan 2015

SUBJECT TO THE PRIVACY ACT OF 1974

Properly dispose of this document after use AUTHENTICATED BY (SFS E6 or Higher):_____________

fill_2:

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SmithRow1:

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AUTHENTICATED BY SFS E6 or Higher:

AUTHORITY Privacy Act of 1974 5 USC Section 522A7 41 USC Section 423 5CFS Section 2635602 AR 34021 Title 10 and 37 USC_2:

DISCLOSURE Voluntary Failure to provide requested information will result in denial of access to DoD facilities_2:

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LEGAL LAST NAMERow1:

FULL FIRST NAMERow1:

FULL MIDDLE NAMERow1:

DATE OF BIRTHRow1:

ISSUING STATE OF IDRow1:

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RANKNOTESRow1:

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LEGAL LAST NAMERow2:

FULL FIRST NAMERow2:

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ISSUING STATE OF IDRow16:

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AUTHENTICATED BY SFS E6 or Higher_2:

Text1:

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