SFS Form1 - Blank.pdf

INDIVIDUAL APPLICATION FOR UNABATED INSTALLATION ACCESS

Controlled Unclassified Information (CUI)/ Law Enforcement Sensitive (LES)

PRIVACY ACT STATEMENT

1. AUTHORITY: 10 U.S.C. 8013; and EO 9397. 2. PRINCIPAL PURPOSE: To record personal information of an individual requesting unabated (unescorted) access on an Air Force installation. To ensure the safety/security of the installation community is not compromised. 3. ROUTINE USES: Information may be disclosed to local, county, state, and federal law enforcement/investigative authorities for investigation purposes (SSAN used for identification and retrieving from files). 4.

DISCLOSURE: Voluntary. Failure to disclose the information, to include SSAN, will result in individual not being allowed access to the installation without escort.

Failure to disclose the information can also result in expulsion or barment from the installation.

1. NAME (Last, First M.): 2. DRIVER'S LICENSE OR ID NUMBER AND STATE OF ISSUE:

3. SSAN OR EQUIVALENT (*optional on form but required at credentialing appointment*): 4. DATE OF BIRTH: 5. SEX:

MALE FEMALE

7. PHYSICAL HOME ADDRESS, CITY, STATE, AND ZIP CODE:

10. REASON FOR REQUESTING ACCESS (Include Company Name if applicable):

6. RACE:

NO YES14. HAVE YOU EVER BEEN ARRESTED? (If yes, please briefly list charge(s)/date/outcome)

13. DAYS OF THE WEEK AND HOURS REQUESTING ACCESS: (Indicate all that apply)

Earliest entry hour:_________________________ Latest entry hour:_____________________________ Su M Tu W Th F Sa

WI CRTC SF FORM 1, 20250220

8. CONTACT PHONE #: 9. VEHICLE (Make, Model, Color, Tag #):

12. SPONSOR INFO. (Name, Unit/Company, Phone #, etc.): 11. DATE(S) REQUESTED:

***STOP! Do not write below this line! SFS Use Only!*** A. Need/Vetting

Need Verified (Blocks 10, 11, and 12 above, confirmed)

CUI/LES

Background/Warrant Check Results: Approved Unescorted Access Denied Unescorted Access (Matrix Category:_____________ )

FPCON Level Authorization: Normal Alpha Bravo Charlie Delta

Vetted By (Name/Signature):_______________________________________

B. Proofing/Credentials Issued

Credential Type/Issue Date:

Credential Number:

Credential Expiration Date:

ID Proofing Completed Date:

Proofed/Issued By (Name/Signature):_______________________________________

ESCORT PRIVILEGES:

Date:_________________ Vetting Completion:_________________

15. I, the above listed individual, swear/affirm that all of the above information is true and correct to the best of my knowledge. I authorize members of the WI CRTC Security Forces Squadron (SFS), using the information provided above, to conduct identity proofing, criminal history records checks, and queries for outstanding arrest warrants (vetting), as prerequisites to me being granted access to Volk Field Air National Guard Base (ANGB) and any other properties under the control of the Volk Field ANGB. I acknowledge that failing to provide true, accurate, and legible information may result in my application being denied or delayed in processing. I understand that the WI CRTC SFS will take all appropriate precautions to safeguard my personal information in accordance with the Privacy Act of 1974. I also understand that, if granted access, it is my responsibility to comply with all applicable rules, laws, regulations, and lawful orders; to maintain custody of my issued access credentials at all times; to return my credentials to the WI CRTC SFS when expired or no longer needed; and to report lost, missing, or stolen credentials to the WI CRTC SFS as soon as possible. Credentials issued based solely on this document do not grant me unescorted access to designated restricted or controlled areas. *Disclaimer: When requested failure or refusal to disclose SSAN may result in denial of unescorted access to or barment from the installation.

Applicant Initials:_____________ Date:______________________

***SF Use Only*** Access Request Number: __________________

Atch 1

Installation Access Fitness Determination Matrix (27 Jan 2025)

1. This guideline is to be utilized by SF personnel vetting individuals requesting unabated installation access. The Commander indicated in the parentheses below “Deny” is the minimum authority necessary to override a denial of unabated installation access as determined by this matrix.

2. This matrix does not list all instances which may disqualify an individual from being granted unabated installation access. A measure of discretion is expected of SF personnel conducting vetting activities, and the SFS Plans and Programs NCOIC reviewing/approving said activities.

3. An inability to identity proof (positively identify) an individual is automatic grounds to deny unabated installation access. Furthermore, any attempts to obfuscate a criminal history or background may also be grounds for denial of unabated installation access.

Nature of Offense A. < 1 Year B. 1-3 Years C. 3-5 Years D. 5-10 Years E. Indefinitely

1. . Hate Crimes, Homicide, Maiming, Arson, Assault (Charged or Convicted)

Deny

(VF CC)

Deny

(VF CC)

Deny

(VF CC)

Deny

(VF CC)

Deny

(VF CC)

2. . Repetitive Criminal Behavior with same offenses (Charged or Convicted)

Deny - 1st Offense

(VF CC)

Deny Deny - 2nd Offense

(VF CC)

Deny - 3rd Offense

(VF CC)

Allow

3. Burglary/Breaking and Entering, Destruction of property, Counterfeiting/Forgery, Domestic Violence, Embezzlement, Non- Registered Sex Offenses, Larceny/ Theft, Motor Vehicle Theft, Robbery no dangerous weapon (Charged or Convicted)

Deny

(VF CC)

Deny

(VF CC)

Deny

(VF CC)

Allow Allow