Selfridge_Base_Access_Form.pdf

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Attached to
Vertical Lift Module Federal contract opportunity
Solicitation number
W912JB18Q5041
Issued by
Department of the Army

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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)

NAME MUST MATCH WHAT IS ON THE DRIVER'S LICENSE

START TIME: _______________ END TIME: ______________

SPONSOR SIGNATURE: SPONSOR AND PHONE NUMBER:

"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). Do not release outside of DoD channels without the consent of the originator's office."

20180815 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: This Access Request form is in draft and subject to revision/update. Please submit any suggestions for improvement to USAF.MI.127- WG.list.Pass-and-Id@mail.mil. 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. The Wing has also indicated if the deadlines as listed above are missed, denials will result. All base access requests must be submitted via a .GOV or .MIL email account.

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DESCRIPTION: Site Visit W912JB-18-Q-5041
BEGIN DATE: 15 AUG 2018
LOCATION: 127 MSC Bldg. 105
END DATE: 15 AUG 2018
START TIME: 10:00 am
END TIME: 12:00 pm
SPONSOR AND PHONE NUMBERRow1:
SPONSOR AND PHONE NUMBERRow1_2:
SPONSOR AND PHONE NUMBERRow1_3:
SPONSOR AND PHONE NUMBERRow1_4:
SPONSOR AND PHONE NUMBERRow1_5:
SPONSOR SIGNATURERow1:
SPONSOR SIGNATURERow1_2:
SPONSOR SIGNATURERow1_3:
SPONSOR SIGNATURERow1_4:
SPONSOR SIGNATURERow1_5:
FIRST NAMERow1:
MIDDLERow1:
JR SRRow1:
DATE OF BIRTHRow1:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row1:
STATE OF ISSUERow1:
GENDERRow1:
RACERow1:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow1:
FIRST NAMERow2:
MIDDLERow2:
JR SRRow2:
DATE OF BIRTHRow2:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row2:
STATE OF ISSUERow2:
GENDERRow2:
RACERow2:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow2:
FIRST NAMERow3:
MIDDLERow3:
JR SRRow3:
DATE OF BIRTHRow3:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row3:
STATE OF ISSUERow3:
GENDERRow3:
RACERow3:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow3:
FIRST NAMERow4:
MIDDLERow4:
JR SRRow4:
DATE OF BIRTHRow4:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row4:
STATE OF ISSUERow4:
GENDERRow4:
RACERow4:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow4:
FIRST NAMERow5:
MIDDLERow5:
JR SRRow5:
DATE OF BIRTHRow5:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row5:
STATE OF ISSUERow5:
GENDERRow5:
RACERow5:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow5:
FIRST NAMERow6:
MIDDLERow6:
JR SRRow6:
DATE OF BIRTHRow6:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row6:
STATE OF ISSUERow6:
GENDERRow6:
RACERow6:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow6:
FIRST NAMERow7:
MIDDLERow7:
JR SRRow7:
DATE OF BIRTHRow7:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row7:
STATE OF ISSUERow7:
GENDERRow7:
RACERow7:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow7:
FIRST NAMERow8:
MIDDLERow8:
JR SRRow8:
DATE OF BIRTHRow8:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row8:
STATE OF ISSUERow8:
GENDERRow8:
RACERow8:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow8:
FIRST NAMERow9:
MIDDLERow9:
JR SRRow9:
DATE OF BIRTHRow9:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row9:
STATE OF ISSUERow9:
GENDERRow9:
RACERow9:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow9:
FIRST NAMERow10:
MIDDLERow10:
JR SRRow10:
DATE OF BIRTHRow10:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row10:
STATE OF ISSUERow10:
GENDERRow10:
RACERow10:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow10:
FIRST NAMERow11:
MIDDLERow11:
JR SRRow11:
DATE OF BIRTHRow11:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row11:
STATE OF ISSUERow11:
GENDERRow11:
RACERow11:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow11:
FIRST NAMERow12:
MIDDLERow12:
JR SRRow12:
DATE OF BIRTHRow12:
DRIVERS LICENSE OR PERSONAL IDENTIFICATION CARD Row12:
STATE OF ISSUERow12:
GENDERRow12:
RACERow12:
COUNTRY OF CITIZENSHIP PASSPORT NUMBER Foreign Visitors onlyRow12:
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Check Box8: Off
Check Box9: Off
Check Box10: Off
Check Box11: Yes
Check Box12: Off
Check Box13: Off
Check Box14: Off
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