EXHIBIT_F-JBPHH_JB2_Form_0-180.pdf

Daily Pass/Valid for 30 Days Only

APPLICATION FOR PERSONNEL AND VEHICLE PASSES FOR LONG TERM VISITOR PASSES AND TO

WORK UNDER NAVY, AIR FORCE, OR LOCAL CONTRACT FOR

CONTRACTORS/VENDORS/EMPLOYEES

(INSTRUCTIONS)

1. All information must be typed; Last Name, First Name, MI, SSN, Citizenship, Gender, Immigration or Passport Number (if applicable)

2. The only information that can be written is date and signatures at the bottom; original signatures are required at time of application.

3. Must show current vehicle registration, safety inspection, certificate of automobile insurance, and driver’s license and/or other form of picture identification for vehicle(s) and driver(s) when picking up badges & Naturalization Certificate/Permanent Resident Card if applicable.

4. All applications for contractors/vendors must be accompanied by a contractor supplied background check (if required by the contract and if not enrolled in NCACS—i.e., optioning for the one-day pass). The most common background checks submitted by contractors/vendors are Precise Hire and Criminal Watch Dog (Advanced National); however, JBPHH does not endorse any particular background check agencies.

5. This letter must be received by Pass and ID 10 days prior to issuing badges. Personnel must pick up their badges within 30 days of the approval date on this letter. Application will be discarded after 30 day and a new one must be submitted.

6. Place of performance/location visiting must be properly annotated. Wahiawa, West Loch, JBPHH Main Base, etc., may be used if a cover letter is submitted with this application documenting the need for base wide access.

7. Visitor Pass expiration date must be entered. Badge expiration date WILL NOT exceed one year.

8. Incomplete forms or forms with errors will be returned for correction; they will not be processed.

9. The form will be e-mailed to the requester’s e-mail address unless otherwise specified on the form.

TO:

JBPHH PASS & ID

1250 SOUTH DRIVE BLDG 3455

HONOLULU HI 96818

FROM: (Sponsor/Organization & Address)

HAWAII AIR NATIONAL GUARD

154th CIVIL ENGINEER SQUADRON

360 MAMALA BAY DRIVE BLDG 3392

JBPHH HI 96853

CONTRACT NUMBER

AND EXPIRATION

DATE

BADGE EXPIRATION DATE

(must be 1 year or less)

DAYS/HOURS

WORKED/VISITING

(Example: Daily/All Hours/Mon-Sat/ 0630-2000, etc. (Limit the daily all hours)

MON-FRI

0600-1800

PLACE OF PERFORMANCE

(Example: Commissary/BX/Onizuka Village Housing/C- 17 Hangar to include Building Number and appropriate

Annex of JBPHH)

JUSTIFICATION:

PERSONNEL/VISITOR LISTING

Last Name First Name MI DOB Place of Birth SSN/Driver’s License # or State ID #

Citizenship Gender Naturalization or

Passport #

(Ex:) Smith John A 4 Jan 1966 Winville, MD 123-45-6789 USA M N/A

THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A FALSE, FICTICIOUS OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED

STATES CODE, SECTION 1001.

COMMAND ENDORSEMENT:

(required for special, spouse, houseguest, and pickup/drop off passes)

Printed Name: 154th CES Organization/Number:

Signature/ Date:

HOUSING OFFICE

ENDORSEMENT:

(required for houseguest passes)

Printed Name:

Housing Office/Number:

Signature/ Date:

REQUESTER SIGNATURE:

REQUESTER NAME:

Phone & Fax No:

E-mail

Sign Sponsor’s Name:

(Day you originally signed form)

Print Sponsor’s

(MILITARY SPONSOR/CONTRACT ADMINISTRATOR AND UNIT/WORK

CENTER)

NHUT L. DAO, Capt, HIANG, 154th CES Environmental Manager/Engineering Flight Chief

Phone/ E-mail:

JBPHH/JB2 Form 0-180 1 AUGUST 2011

Daily Pass/Valid for 30 Days Only

PRIVACY ACT STATEMENT

AUTHORITY: Section 3101, Title 44, US Code, 5 USC 552A PRINCIPAL PURPOSES: The purpose of requesting personal information is to assist security personnel in developing records to document contractor employee suitability for access to Joint Base Pearl Harbor-Hickam, Hawaii to work under Navy, Air Force, or local contracts. The social security number and date and place of birth are necessary to identify persons, maintaining records, and for criminal history/background checks.

ROUTINE USES: This information may be used to determine suitability of persons desiring access to Joint Base Pearl Harbor-Hickam as well as for other lawful purposes including law enforcement and litigation.

DISCLOSURE IS VOLUNTARY: Disclosure of requested information is voluntary. However, failure to provide information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the contract while serving in the capacity of prime contractor or subcontractor/supplier/employee.

NCIC/BACKGROUND CHECK DATE: ______________ SOURCE USED: _____________________ SRBW CHECK: ___________ TERRORIST DATABASE CHECK DATE:_________________ SEX OFFENDER DATABASE CHECK DATE:_________________

PRINTED NAME/SIGNATURE OF PID REPRESENTATIVE __________________________________________________________

PERSONNEL LISTING (continued)

Last Name First Name MI DOB Place of Birth SSN Citizenship Gender Naturalization or

Passport #

(Ex:) Smith John A 4 Jan 1966 Winville, MD 123-45-6789 USA M N/A

Sign Sponsor’s

(Day you originally signed form)

Print Sponsor’s

(MILITARY SPONSOR/CONTRACT ADMINISTRATOR AND UNIT/WORK

CENTER)

NHUT L. DAO, Capt, HIANG, 154th CES Environmental Manager/Engineering Flight Chief

Phone/ E-mail:

JBPHH/JB2 Form 0-180 (Page 2)