175th_WING_INSTALLATION_ACCESS_APPLICATION.pdf

INSTALLATION ACCESS APPLICATION DATE

WG FORM 113, 20140905 PREVIOUS EDITIONS ARE OBSOLETE

PRIVACY ACT STATEMENT

AUTHORITY AND PURPOSE: Under authority DoD 5200.08R, AFI 31-101, AFI 31-113 and WI 31-113. This application form requires the collection and maintenance of information protected by the Privacy Act of 1974 for the purpose and ability to establish identification of all personnel requiring access to the Warfield Air National Guard Base, Middle River, Maryland.

DISCLOSURE: 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 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 the Wing Commander or their designated representatives. You will also understand that you must immediately report a lost pass to the 175th Security Forces Squadron.

I. Access Information

II. Personal Demographics

III. Vehicle Information

IV. Employer Information

PROJECT NAME/ DESCRIPTION DATES REQUESTED

HOURS REQUESTED

WORKDAYS REQUESTED

FROM TO

FROM TO

Monday Tuesday Wednesday Thursday Friday

NAME (last, first, middle)

HOME ADDRESS

GENDER HEIGHT WEIGHT EYE COLOR

DATE OF BIRTH

ID TYPE

SOCIAL SECURITY #

ID #

VEHICLE 1 MAKE

VEHICLE 2 MAKE

MODEL

MODEL

VEHICLE 3 MAKE MODEL

VEHICLE 4 MAKE MODEL

LIC PLATE W/ ST

LIC PLATE W/ ST

LIC PLATE W/ ST

LIC PLATE W/ ST

VEHICLE 5 MAKE MODEL LIC PLATE W/ ST

EMPLOYER NAME

EMPLOYER ADDRESS

SUPERVISOR NAME PHONE #

Signature:Print Name:

Click to sign