Vetting_Access_Request_List_Blank.pdf

LAST NAME FIRST NAME MIDDLE JR / SR DATE OF BIRTH

DRIVER'S LICENSE # OR

PERSONAL IDENTIFICATION

CARD #

STATE OF

ISSUE GENDER RACE

COUNTRY OF CITIZENSHIP /

PASSPORT NUMBER

(Foreign Visitors only)

"PRIVACY ACT STATEMENT: This electronic transmission may contain FOR OFFICIAL USE ONLY (FOUO) information that must be protected under the Privacy Act of 1974 (see AFI 33-332). NOTE: Due to the new update to DBIDS, either a social security card, tax ID number, or certificate of naturalization must be shown at the time of issue.

NAME MUST MATCH WHAT IS ON THE DRIVER'S LICENSE

START TIME: _______________ END TIME: ______________

SPONSOR SIGNATURE: SPONSOR AND PHONE NUMBER:

SELFRIDGE ANGB PRE-AUTHORIZATION ACCESS REQUEST LIST. (Please type or print clearly!)

COMPANY/EVENT: BEGIN DATE: DAYS (indicate): SUN MON TUE WED THU FRI SAT

LOCATION ON BASE/BLDG #: END DATE:

NOTE: Submit completed form to USAF.MI.127-WG.list.Pass-and-Id@mail.mil. Requests deadlines are as follows; for lists up to 30 names a MINIMUM of 3 business day notice, 31-75 names a MINIMUM of 5 business day notice and over 75 guests a MINIMUM OF 10 business day notice. These are suggested guidlines, not following these guidlines may delay processing of vetting requests.. All base access requests must be submitted via a .GOV or .MIL email account.

Previous Edition Obsolete March 2018

1. Authority: Air Force Manual 31-133, Installation Perimeter Access Control

2. Information provided will be entered into Michigan Law Enforcement Information Network, for vetting process.

3. Disclosure: Disclosure of this information is voluntary; however failure to provide the requested information will prevent further processing of this request.

1039496620N Highlight

1039496620N Typewritten Text

1039496620N Highlight

1039496620N Highlight