Site Visit Access Request Form (Parks RFTA).pdf

PARKS RFTA ACCESS REQUEST FORM (THIS FORM IS

SUBJECT TO THE PRIVACY ACT OF

1974) ALL REQUESTS MUST BE SUBMITTED IN

TO THE VISITOR CONTROL CENTER OR PHYSICAL SECURITY OFFICE

ROUTINE VISITS AND OTHER

SPECIAL EVENTS (CHECK ONE)

CONTRACTOR/VENDOR ACCESS

CREDENTIAL (CHECK ONE)

Complete this form and return Parks RFTA sponsor. A National Crime and Information Center (NCIC) check will be conducted prior to granting access to the installation.

By signing this application, you affirm/swear the information provided is true. That a knowing and willful false statement on this application can be punished by being barred from the installation, a fine, imprisonment or both. (18 U.S.C. Section 1001). Furthermore, that under the authority of 50 U.S.C. Section 797 and DoD 5200.8, the installation commander has imposed a continuing obligation for you to disclose. Questions may be directed to the Physical Security office at (925)875-4658 or (925)875-4656

Section 1. PERSONAL INFORMATION (FAILURE TO PROVIDE ALL INFORMATION MAY RESULT IN DENIED ACCESS)

1. NAME (Last, First, Middle) 2. DRIVER’S LICENSE NUMBER / State 3. SOCIAL SECURITY NUMBER 4. DATE OF BIRTH (YYYYMMDD)

5. CURRENT ADDRESS (Include City/State/ZIP Code) 6. HOME PHONE NUMBER WORK PHONE NUMBER

7. SEX 8. RACE 9. EYE COLOR 10. HAIR COLOR 11. HEIGHT 12. WEIGHT

Section 2. PLACE OF BIRTH

1. CITY 2. STATE (If applicable) 3. COUNTRY

4. U.S. CITIZEN? (If no, answer question 5) 5. LIST IMMIGRATION DOCUMENT TITLE, DOCUMENT NUMBER, AND EXPIRATION DATE (If applicable)

Section 3. CONTRACTOR/VENDOR INFORMATION (IF APPLICABLE) The following company/organization is providing either vendor’s service or holds a contract with our organization. The individual is required to enter Fort Hunter Liggett, CA in an official capacity on a regular basis. Request the issuance of an access credential.

The below listed individual understands that this is an identification credential, not a sponsoring credential and that it will not allow entry into any facilities other than the installation gates. Use of this credential is strictly for business purposes only. Individual agrees to adhere to all vehicle regulations and guidelines set forth by AR 190-5, Army Motor Vehicle Regulation and those set by the installation commander.

1. COMPANY / ORGANIZATION NAME 2. FULL ADDRESS OF COMPANY / ORGANIZATION (Include City/State/ZIP Code)

Section 4. GOVERNMENT SPONSOR OR CONTRACT REPRESENTATIVE - AUTHORIZING INFORMATION Upon termination of contract, employee termination, or expiration of the access credential the Authorizing Official will retrieve the credential from the contractor and return it to buildings 275 VCC or 620 Physical Security. The Government Sponsor must complete their portion before it is accepted at the Visitor Control Center. Being a sponsor you assume all responsibility for your visitor while they are on the installation.

1. NAME (Last, First, Middle) 2. OFFICIAL TITLE 3. ORGANIZATION 4. WORK PHONE

5. OFFICIAL EMAIL ADDRESS 6. CONTRACT NUMBER (Required if sponsoring a contractor)

THE SPONSOR AGREES TO ACCEPT RESPONSIBILITY FOR THEIR VISITOR(S) WHILE ON THE INSTALLATION:

SPONSOR’S SIGNATURE: ___________________________________________________ DATE: _______________________________

Section 5. WARNING: CONSENT TO SUBJECT SEARCH/SEIZURE, VEHICLE TOWING, REIMBURSEMENT, IMPOUNDMENT By accepting a visitor/contractor pass you give your consent to search of your vehicle while it is entering on, or leaving Fort Hunter Liggett. If your vehicle is towed or impounded, you agree to reimburse the towing agent on behalf of the vehicle owner/operator.

Section 6: ATTESTATION I understand the information on this form is being collected in accordance with 50 U.S.C., Section 797, and DoD 5200.8, and federal laws. Permitting the installation commander to limit access to the installation for security reasons and that this data will be used to screen personnel who have or are seeking access to Fort Hunter Liggett. I have voluntarily completed this form and shall provide the Army a specimen of my fingerprints, if/when requested. I understand (a) criminal offense(s) may be prosecuted in federal court. The information I have provided on this application is true, complete, and correct to the best of my knowledge and belief, and is provided in good faith. I understand that a knowing and willfully false statement on this application can be punished by fine or imprisonment or both (18 U.S.C section 1001).

Date(s) of visit/contract term requested: __________________________________________________ Date ofRequest:______________________________

Should access be denied, you may request a denial wavier through the Directorate of Emergency Services-Physical Security Office the point of contact for denial wavier actions. Follow the instructions on second page of the wavier for submittal instructions, address, and documentation requirements.

Section 8. PRIVACY ACT STATEMENT Authority: 50 USC Section 797; E.O.9397

PRINCIPAL PURPOSE(S): The purpose for requesting personal information is to assist Access Control personnel in documenting visitors’ suitability for access to Fort Hunter Liggett. Social security number and date of birth are necessary to identify the person and records. This information may be used to determine suitability of person desiring access to Fort Hunter Liggett; as well as, for lawful purposes including law enforcement and litigation. This information will be used to generate state and federal criminal history records checks.

INTENDED USE: For all personnel who are not authorized a Common Access Card (CAC) or other federally authorized credential and require access to the installation for a special event and/or visit.

DISCLOSURE: Disclosure of requested information is voluntary; however, failure to provided information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the special event and/or visit. For Official Use Only (FOUO), This document contains information exempt from mandatory disclosure under the FOIA. Title 5 U.S.C. 552 (b) (6) applies. This document also contains personal information that is protected by the Privacy Act of 1974 and must be safeguarded from unauthorized disclosure."

Section 9. Approval or Denial (To be completed by DES Personnel) 1.

Access Granted

2.

Access Denied

3. 4. 5.

Print Name Signature Date

6. DATE REQUEST RECEIVED: 7. DATE SPONSOR NOTIFIED OF APPROVAL/DISAPPROVAL:

INSTALLATION ACCESS REQUEST FORM, 1 March 2016 All previous editions are obsolete

CLETS MSG#_____________________________ Page 1 of 1

Initial Extend

Initial Renew

Purpose:

Section 7. Access Denials

For Official Use Only (FOUO)

ACCEPTABLE DOCUMENTS FOR VERIFICATION OF IDENTITY/AUTHORIZATION TO WORK

ANY ONE OF THE DOCUMENTS BELOW

ID card issued by a state or outlying possession of the United States provided it contains a photograph and information such as name, date of birth, gender, height, eye color, and address

US PASSPORT

CERTIFICATE OF NATURALIZATION ( Form N-550 or N-570) FOREIGN PASSPORT w/

I-551 Stamp or Fm I-94 showing employment authorization

PERMANENT RESIDENT CARD or ALIEN REGISTRATION CARD

I-151 or I-551 (Must contain photographs)

ADDITIONAL DOCUMENT REQUIREMENTS:

SSN NUMBER

IF OPERATING A VEHICLE YOU MUST PRESENT A REAL ID ACT OF 2005 COMPLIANT VALID DRIVER

LICENSE, CURRENT REGISTRATION, AND PROOF OF VALID INSURANCE

NOTE:

2. Persons who do not pass the security vetting will be denied access and provided with the process for submitting a wavier. The denial wavier process is governed by Army Directive 2014-05 and is non-waiverable. The appeal process can take an extended period of time.

3. Visitor Center staff may contact a Company POC listed on the access request form to verify that the request for a pass is valid.

4. All information on the access request form must be completed. The completed form and the verification documents listed above are to be presented to Visitor Center Staff or Physical Security Office. Access request forms may be emailed to: usarmy.parks.imcom.list.vcc@mail.mil

5. Any conduct which is detrimental to the maintenance of good order and discipline on the Parks RFTA Military Installation may result in confiscation of the visitor pass/badge, immediate removal from the installation, and the imposition of a BAR.

6. The Government Agent (sponsor) has overall responsibility for the conduct of the pass holder at all times while they are on the Installation. While this does not include punitive liability, the Agent may be required to brief senior installation leaders regarding acts of employee misconduct.

7. Pass holders will confine themselves only to those Areas and Hours related to issuance of the Pass.

Pass holders will not enter any marked, restricted and/or controlled areas. Specifically airfields, command headquarters, motor pools, military training facilities, military barracks, housing areas other than those where you are an invited guest, areas where military weapons are present, fire stations, and communications facilities. Be prepared to identify yourself and the purpose of your presence on PRFTA to police or security personnel at all times.

8. Vehicles and packages are subject to random search at any time while on the installation.

9. Firearms and other personal weapons are prohibited except for specific sporting activities.

10. Any firearm brought onto PRFTA property for a legitimate activity is required to be registered with the Provost Marshal

11. Concealed weapons permits are not valid on the installation.

1. a. Screening and vetting personnel records.

All personnel requesting access will be subject to Vetting, a records check through the National Crime Information Center (NCIC) Interstate Identification Index (III) is the minimum baseline background check for entrance onto Army installations for non-CAC holders to include entrance of visitors and Contractors.

b. Vetting to grant access, does not grant the right to work.