WF_113_-_Installation_Access_Application.pdf

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175 WG FORM 113, 20170207

Page of

PREVIOUS EDITIONS ARE OBSOLETE

INSTALLATION ACCESS APPLICATION

SECTION 1 - ACESSS INFORMATION

Have you EVER been arrested, cited or detained by any law enforcement officer (including any immigration official or any official of the U.S. Armed Forces) for any reason?

SECTION 3 - VEHICLE INFORMATION

SECTION 4 - EMPLOYER INFORMATION

DATES REQUESTED

HOURS REQUESTED

WORKDAYS REQUESTED

SECTION 2 - PERSONAL DEMOGRAPHICS

PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C., DoD 1400.34 SC 1950 and Title 10 U.S.C., 8013; SECAF E.O. 9397 authorizing SAN to be used as a system of numbering to identify persons.

PURPOSE: To provide a means of positive identification for the purpose of processing applications or retrieving data.

ROUTINE USES: Blanket DoD routine uses.

DISCLOSURE: Voluntary: However, failure to provide the requested information will result in delay or termination of your request.

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.

11.0.1.20130826.2.901444.899636 TSgt Laura Turner

175 SFS/SFA

SSgt Chris Petry 175 WG Form 113 - Installation Access Application