INDIVIDUAL_APPLICATION_FOR_MERCHANT_PASS_1.pdf

INDIVIDUAL APPLICATION FOR MERCHANT PASS (UNOFFICIAL BUSINESS)

(ENSURE DATA IS LEGIBLE AND COMPLETE)

PRIVACY ACT STATEMENT

1. AUTHORITY: 10 U.S.C. 8013; and EO 9397. 2. PRINCIPAL PURPOSE: To record personnel information on an individual who requires long-term access on an Air Force installation for unofficial business. To ensure the safety 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 (SSN used for identification and retrieving from files). 4. DISCLOSURE: Voluntary.

Failure to disclose the information, to include SSN, will result in individual not being allowed to conduct business on the installation without escort or sponsorship. Failure to disclose the information can also result in expulsion or barment from the installation.

LAST NAME: FIRST NAME, MIDDLE INITIAL:

SSN: DOB:

SEX: (Circle one)

MALE FEMALE

ADDRESS, CITY, AND ZIP CODE:

DRIVER'S LICENSE NUMBER AND STATE OF ISSUE: RACE:

ALABAMA RESIDENT FOR LAST 7 YEARS: (Circle one) NO YES

IF NO, NATIONAL BACKGROUND CHECK REQUIRED

NOTE: IF PERSON HAS MILITARY ID (Active or Reserve), NO BACKGROUND CHECK REQUIRED

HAVE YOU EVER BEEN CONVICTED OF A CRIME? (Circle one) NO YES IF YES, EXPLAIN IN DETAIL NATURE OF OFFENSE AND OUTCOME (ON SEPARATE SHEET OF PAPER)

COMPANY:

DAYS OF THE WEEK AND HOURS REQUESTING AUTHORIZATION TO ENTER MAXWELL AFB FOR BUSINESS PURPOSES ONLY: (Indicate all that apply)

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

I authorize the use and release of my personal information to the 187 Fighter Wing, to accomplish preliminary criminal background checks to determine access to 187 Fighter Wing Air National Guard Base in connection with proposed unofficial business. Merchant Pass is Government Property and I understand that I will be held accountable for its use and security. If I lose my pass, I understand an updated background check by the Alabama Bureau of Investigation is required before the pass will be reissued. All the information listed on this application is true and accurate to the best of my knowledge.

Signature of Employee:____________________________________ Date:_____________________

This person represents my company. I have reviewed this information and verify it is correct.

Signature of Company Representative:__________________________________ Date:_______________________

DO NOT WRITE BELOW -GOVERNMENT USE ONLY

BACKGROUND CHECK DATE COMPLETED:

BACKGROUND CHECK RESULTS: (Circle one)

Disapproved Approved

FPCON Level Authorization: (Circle highest level)

Normal Alpha Bravo Charlie Delta

CARD ISSUE DATE:________________________________

EXPIRATION DATE:________________________________

(1 year from issue date)

PROCESSED BY:__________________________________

CARD NUMBER:___________________________________

DANNELLY FIELD ANGB FORM 9, 20150916 PREVIOUS EDITIONS ARE OBSOLETE