CBKS228RE BASE ACCESS FORM.pdf

CARLISLE BARRACKS INSTALLATION

ACCESS CONTROL APPLICATION

Please provide the following information for completion of a National Crime Information Center (NCIC) and Army Law Enforcement Reporting and Tracking System (ALERTS) Installation access check.

NAME: ____________________________________ __________________________

Last, First, Middle Maiden (If applicable)

SSN#: DRIVERS LICENSE # / STATE ID #: STATE:

DOB: ___________________________ PRIMARY PHONE:______________________ SEX: ______ (Date of Birth) YYYY/MM/DD

HOME ADDRESS: ________________________________________________________

Street City State Zip

REASON FOR VISIT:

GOVERNMENT SPONSOR INFORMATION:

(NAME/AGENCY/PHONE #)

END DATE OF PASS REQUESTED: __________________ ______________________________

(NOT TO EXCEED ONE YEAR) GOVERNMENT SPONSOR SIGNATURE

NO GOVERNMENT SPONSOR REQUESTED END DATE OF PASS: __________________

NOT TO EXCEED 30 DAYS

I have been advised that my gaining access to the Carlisle Barracks Installation is contingent upon successful completion of a criminal history background check. I understand that the background check includes accessing information within the NCIC and ALERTS. I have been advised that all information received from these checks will be maintained within the Directorate of Emergency Services and properly destroyed at the completion of the purpose of request.

SIGNATURE OF APPLICANT: _______________________________________

LAW ENFORCEMENT USE BELOW THIS LINE ONLY

( ) No adverse information found.

( ) Adverse information found Installation Access Control is cleared by this office.

( ) Adverse information found Installation Access Control is NOT cleared by this office.

PRINT NAME / SIGNATURE / DATE ____________________________________________________

INITIALS & DATE OF CHECK ONLY

DL NCIC ALERTS PASS#

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY: 5 USC 552a(b), 10 USC 3013, Title 10 United States Code, Section 3012(g), E.O. 9397 PRINCIPLE PURPOSE: To provide law enforcement officials with means by which information may be accurately identified in order to enforce security provisions.

ROUTINE USE: Your social security number is used as an additional/alternate means of identification to facilitate filing and retrieval.

DISCLOSURE: Disclosure of your social security number is voluntary. Failure to disclose the information requested precludes consideration of an application for access to the Carlisle Barracks Installation through the use of a temporary pass or as part of an event list. Personnel not submitting to a background check will be denied unescorted access to the Carlisle Barracks Installation.

CBks (DES) Form 228-R-E Rev May 6