Form 21.xlsx
XLSX spreadsheet 19 KB Posted
- Solicitation number
- W91QV119R0012
View the file
Other files
Show 40 more
Latest 50 of 74 listed here. See the rest on GovTribe.
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Sheet1
| Request for Unescorted Installation Access | |||
| For use of this form, see Army Regulation 190-13, "Installation Access" and the "Instructions" page. The proponent agency is DPTMS. | |||
| PRIVACY ACT STATEMENT | |||
| AUTHORITY: | Army Regulation 190-13, "Army Physical Security Program", February 25,2011; Directive-Type Memorandum 09-012," Interim Policy Guidance for DoD Physical Access Control", March 19, 2013, Title 18, USC Section 1382 | ||
| PRINCIPAL PURPOSE: | To facilitate vetting, identity proofing and verification of purpose for accessing the installation as required by DTM 09-012 and the check of National Crime Information Center (NCIC) Interstate Identification Index (III) records as required by AR 190-13. | ||
| ROUTINE USES: | Information will be processed through the National Crime Information Center (NCIC) Interstate Identification Index (III) database to determine criminal history (AW AR 190-13. Personal information for individuals who are authorized to access the installation as a result of this request will be maintained on the installation access roster for the duration of the authorized access period. Personal information for individuals who are denied access to the installation as a result of this request will be maintained on the installation access roster for approximately one year after the submission of the request. | ||
| DISCLOSURE: | Disclosure is voluntary; however, failure to provide the information may result in the inability to process an individual's request for unescorted access to U.S. Army Garrison, Fort Betvoir at Rivanna Station. | ||
| THIS SECTION TO BE COMPLETED BY COMPANY, ORGANIZATION,OR VISITING INDIVIDUAL. PLEASE REVIEW THE "INSTRUCTIONS' PRIOR TO COMPLETING THIS FORM. | |||
| CO or ORG*: | Dates of Access Request*: | Through* | |
| CO/ORG Point of Contact*: | Point of Contact Email Address*: | ||
| Contract #: | Point of Contact Telephone #*: | ||
| CAGE code: |
| THIS SECTION TO BE COMPLETED BY GOVERNMENT SPONSOR | ||
| Government Sponsor*: | Sponsor Organization*: | |
| Purpose of Visit*: | Sponsor Telephone #*: |
Full Last Name* Full First Name* Full Middle Name Date of Birth* State License/ID, U.S. Passport or Resident Allen #*
| DPTMS (RS) Form 21 | FOR OFFICIAL USE ONLY | ||||
| Revised 05 Feb 2014 | |||||
| Full Last Name* | Full First Name* | Middle Name | Date of Birth* | State License/ID, U.S. Passport or Resident Allen #* |
| DPTMS (RS) Form 21 (Back) | FOR OFFICIAL USE ONLY |
| Revised 05 Feb 2014 |
File details come from the government source that posted it. Updated .