Base_access_form.doc

175th WING INSTALLATION ACCESS APPLICATION

DATA REQUIRED BY THE PRIVACY ACT OF 1974

(Sections 3013, 5013, and 8013. Title 10 United States Code, Executive Order 9397, and U.S.C. Section 552a)

AUTHORITY: DOD 5200.08R, AFI 31-101, AFI 31-113 and Wing Instruction 31-601.

PRINCIPLE PURPOSE: To establish identification of all personnel requiring access to Warfield Air National Guard Base, Baltimore, Maryland.

MANDATORY DISCLOSURE REQUIREMENT: Failure to provide the below requested information, including social security number, valid state drivers license or identification card number and accurate personal demographic information will result in the disapproval of this application. Disapproved applicants will be denied access to the installation. Personal information contained within this application will be handled as OFFICIAL USE ONLY in accordance with U.S. federal statutes.

CONDITIONS APPLICABLE ON RECEIPT: By virtue of signing this application and upon receipt of a Wing Contractors Pass you understand that this pass is only valid at Warfield Air National Guard Base for the dates requested on this application. It is understood that the pass is the property of the 175th Wing, it is not transferable, and if it is altered in any way access will be denied. It must be surrendered at the request of the 175th Wing, its designated representatives or the issuing agencies. You will understand that while on Warfield Air National Guard Base, your person, possessions, vehicle and work area are subject to search at the discretion of Wing Commander or their designated representatives. You will also understand that you must immediately report a lost pass to the 175th Security Forces Squadron.

SECTION 1-Access Information

SECTION 2-Personal Demographics

NAME (last, first, middle)

HOME ADDRESS

GENDER

HEIGHT

WEIGHT

EYE COLOR

DATE OF BIRTH

SOCIAL SECURITY #

ID TYPE

ID #

SECTION 3-Vehicle Information

VEHICLE 1 MAKE

MODEL

LIC PLATE W/ST

VEHICLE 2 MAKE

MODEL

LIC PLATE W/ST

VEHICLE 3 MAKE

MODEL

LIC PLATE W/ST

SECTION 4-Employer Information

EMPLOYER NAME

EMPLOYER ADDRESS

SUPERVISOR

PHONE NUMBER

SIGNATURE:_________________________________________