Attachment_1_-_JBM-HH_Installation_Access_Request.pdf

JBM-HH Form 190-16x, 16 May 18

Joint Base Myer-Henderson Hall (JBM-HH) Installation Access Request For use of this form, see JBM-HH Reg 190-16, Proponent is Directorate of Emergency Services

Privacy Act Advisement: The information requested is for the purpose of granting access to the JBM-HH installation. Providing requested information, to include your social security number (SSN), is voluntary. However, your access may not be granted if all requested information is not provided. Authorities: Executive Orders (EO) 10450, 10865, and 12333. The SSN, required for record accuracy, is requested pursuant to 10 U.S.C. 3013, Secretary of the Army; AR 190-13, The Army Physical Security Program, and EO 9397. Principal Purpose(s): The information collected on this form is used to screen and identify access applicants to JBM-HH who may have criminal histories or involvements which preclude installation access. Completed forms are used to conduct background records checks for determinations of the eligibility of applicants for access to JBM-HH.

Completed forms are covered by official SORNs. Disclosure: Voluntary. However, failure of the applicant to complete any of the applicant required sections may result in refusal of access to JBM-HH. An applicant’s SSN is used to conduct law enforcement records checks and Government data base queries. All information is “For Official Use Only” and will only be released to the JBM-HH Police Department or other authorized agency personnel for the purposes of determining access eligibility and/or enforcing Federal, state, local law or regulations. Information retrieved from law enforcement records checks and Government data base queries will not be disclosed to the applicant IAW National Crime Information Center and Interstate Identification Index laws, user agreements, Army Directive 2014-05 and official guidance.

Section A. Visitor Applicant Information

Type of Applicant: (check appropriate box)

VISITOR CONTRACTOR OTHER ___________________

1. Name (last, first, middle initial): 2. Date of Birth: 3. Gender:

Male

Female

4. Race:

5. Social Security Number: 6a. Driver’s License or State ID Number: 6c. U.S. or U.S Territory Passport Number (if state driver’s license or ID not available): 6b. Issuing State or Territory:

7. Residential Address: (Include City/State/ZIP Code) 8. Home Phone Number: 9. Cellular Phone Number:

10. Are you a U.S. Citizen?

Yes No

If you are a U.S. Citizen, skip questions 10a thru 10d

10a. Do you have a Visa, Foreign Passport or Official Military Orders allowing travel, work or residency in the U.S.?

Yes No

Please indicate what documentation you have and the corresponding alphanumeric number: ___________________________________________________

10d. Do you have a Foreign National Number (FNN): Yes No

(If yes, list your FNN: __________________________________________________________________________)

10b. Work Authorization Card (aka; Employment Authorization Card): Form I-766 Permanent Resident Card (aka; Green Card): Form I-551

List the alphanumeric identifier for your work authorization document: ________________________________________________________________________________

10c. Do you have a Alien Registration Number (ARN): Yes No

(If yes, list your ARN: ______________________________________________________________________________________)

Note: If you are a non-U.S. citizen, you must provide all relevant documentation for verification. The visitor Control Center (VCC) is required to make and retain photocopies of all docu-mentation which allows you to work, reside or visit the U.S. for the purpose of installation access.

Section B. Contractor/Vendor Information (If Applicable)

1. Contractor/Vendor Company Name: 2. Company Phone Number:

4. Contractor/Vendor Address: (Include City/State/ZIP Code) 5. Contractor/Vendor Company Point of Contact:

3. Contract Number: (if applicable)

6. Contractor/Vendor Applicant Category:

Place a check beside the description which best describes your contract category.

CAC eligible Contractor Non-CAC eligible Contractor

7. Requested Duration of Access:

(Not to exceed one year)

8. Contract Dates and Work to Be Performed:

11. Applicant Category: Please place a check beside the description which best describes your category.

Non-DoD Affiliate Visitor Gold Start Family Member Foreign Military Member on Official Orders Taxi/Limo/Uber or Lift Driver Foreign National

Family Care Provider Employee of JBM-HH Resident Volunteer Tow Truck Driver Commercial Delivery Moving Company

Guest of JBM-HH Resident DRMWR Member Event Attendee Thrift Shop Other _____________________________________

12. Requested Duration of Access: (not to exceed 1 year) Requested Date(s)/Time(s) of Visit

From Date: _______________________________________ To Date: _________________________________________

From Time: ________________________ To Time: ____________________________

13. Justification for Pass:

JBM-HH Form 190-16x, 16 May 18

Section E. Background Verification

Security Force Use Only– Applicant Does Not Fill Out This Section

1. Type of NCIC-III Check Completed: VCIN WALES

Result: Derogatory Information Found No Derogatory Information Found

No Record Match

2. TSDB Check Completed: YES NO

Derogatory Information Found No Derogatory Information Found N/A

3. ALERTS Check Completed: YES NO

Derogatory Information Found No Derogatory Information Found N/A

4. Does a Waiver packet need to be provided to the applicant?

YES NO

5. If yes, was a Waiver packet provided to the applicant? YES NO

6. How was the waiver packet delivered to the applicant?

In Person Via email to the sponsor Other: ___________________ N/A

7. If a waiver packet was not provided to the applicant or sponsor, please explain why:

1. Printed Name: (last, first, middle initial): 2. Signature: 3. Date: (month, day, year)

Section F. Pass Information

1. Type of Pass Issued: Approved Disapproved

24 Hour Visitor Pass 30 Day Visitor Pass 60 Day Visitor Pass 90 Day Visitor Pass 6 Month Visitor Card 1 Year Visitor Card

Other (explain type of pass and length): ___________________________________________________________________

Validity Date Range of Pass: From ___________________________________ To ______________________________________

Section G. Security Force Conducting Check and Issuing Pass Information

Disposition: This information will be retained and kept on file for two years.

Section D. Sponsor Information

1. Name (last, first, middle initial): 2. Grade/Rank/Status: 3. Date of Birth: 4. Gender:

Male Female

5a. Driver’s License or State ID Number: 5b. Issuing State or Territory: 5c. U.S. or U.S Territory Passport Number (if state driver’s license or ID not available): 6. Work Phone:

7. Organization/Unit (for Active Duty or Civilian DoD Employees Only): 8. Government Email:

11. Sponsor’s Certification:

I certify that the applicant meets the justification requirements as indicated in JBM- HH Regulation 190-16, Access Control Policy, for access privileges. Furthermore, I certify that the applicant requires a Visitor Pass as indicated above in order to per-form assigned duties, conduct official business or has valid purpose for JBBMH-HH access.

11a. Sponsor’s Signature: (invalid if incomplete)

9. Are you the COR or CoTR:

Yes No

10. If you are not the COR or CoTR, list the name, telephone number and email of the COR or CoTR:

Name: _______________________________________________________________ Phone: _____________________________________ Email: _______________________________________________________

2. Applicant’s Signature:

The data retrieved for installation access vetting is “For Official Use Only” and will be maintained and used in strict confidence in accordance with Federal, state, local laws and regulations.

Personnel record screening, utilizing the National Crime Information Center and Interstate Identification Index (NCIC-III), the Virginia Criminal Information Network (VCIN), the Washington Area Law Enforcement System (WALES), the Terrorist Screening Data Base (TSDB), Army Law Enforcement Reporting and Tracking System (ALERTS) and Installation Debarment Lists, is a voluntary process. Applicants requesting JBM-HH access are not required to submit to personal record screening; however person(s) who elect not to authorize the personnel record screening and vetting process will not be granted access to JBM-HH whether escorted or unescorted.

By signing below the applicant asserts the following:

-I certify that, to the best of my knowledge and belief, all of the information on and attached to this request for JBM-HH Installation Access Control Pass request, including any attached application materials, is true, correct, complete, and made in good faith.

-I understand that a false or fraudulent answer to any question or item on any part of this application or its attachments may be grounds for the denial of installation access.

-I understand that any information I give may be verified and/or examined for the purpose of determining eligibility for JBM-HH installation access and/or the execution of Federal, state, local laws and regulations.

-I consent to the release of information about my criminal history from law enforcement or criminal justice agencies, law enforcement state or federal data bases, criminal history record information, federal installations or properties and other authorized employees or representatives of the Federal Government.

-I understand that my consent is voluntary and I may refuse to give my consent.

-I understand I have the right to refuse authorized representatives of JBM-HH to obtain my criminal history.

I understand that derogatory results of any such inquiries may result in the denial of installation access and/or the execution of an outstanding legal service or warrant from information obtained through authoritative law enforcement data bases.

-I understand that information released by records custodians and sources of information is for the official use by the Federal Government only for purposes provided in this form, and may be redisclosed by the Government only as authorized by law. Copies of this authorization that show my signature are as valid as the original release signed by me.

-I assert I understand all of the information stated herein and have requested clarification or explanation of any terms, concepts or procedures which were unclear to me.

-I hereby consent to have my name and provided identifying information vetted utilizing any or all of the following systems: NCIC -III, VCIN, WALES, the TSDB and ALERTS.

Section C. Authorization For Criminal Records Release

1. Applicant’s Printed Name (last, first, middle initial): 3. Date: (month, day, year)