Attachment IV - Request for Access to Tobyhanna Army Depot

Request for Access to Tobyhanna Army Depot
Use in accordance with Directive Type Memorandum (DTM) 09-0012 "Interim Policy Guidance for DoD Physical Access Control" dated 22 APR 14. Proponent Office is ELTY-ISR-S.

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 United States Code, Section 3013
In conjunction with "Directive Type Memorandum (DTM)" 09-012 "Interim Policy Guidance for DoD Physical Access Control", dated 22 PRINCIPAL PURPOSE: Apr 14, this form is intended to ensure that force protection measures are implemented for all non-DoD - credentialed personnel who request access to the installation.
ROUTINE USES: To control and maintain force protection requirements.

DISCLOSURE:

APPLICATION

DATE

Voluntary civilian. Failure to provide information deemed "mandatory" may result in a processing delay of your request for access or a denial of your request.

REASON FOR REQUEST

FOR CRIMINAL HISTORY BACKGROUND CHECK

FIRST NAME

DATE OF ANTICIPATED VISIT OR YELLOW

CONTRACTOR BADGE EXPIRATION DATE

MIDDLE NAME

AREAS OF TYAD

TO BE VISITED

LAST NAME

OTHER NAMES USED / ALIASES

STREET ADDRESS

PHONE NUMBER

STATE

CITY

ZIP CODE

DRIVER'S LICENSE

STATE

RACE

SEX

DATE OF BIRTH STATE OF BIRTH COUNTRY OF BIRTH

DRIVER'S LICENSE NUMBER

SOCIAL SECURITY NUMBER

TOBYHANNA FEDERAL EMPLOYEE POINT OF CONTACT (POC)

POC NAME

POC PHONE NUMBER

POC EMAIL ADDRESS

POC DIRECTORATE

CRIMINAL HISTORY BACKGROUND CHECK RELEASE AND CONSENT

I hereby authorize the Tobyhanna Army Depot Security Branch to receive any criminal history/background information pertaining to me which may be in the files of any Federal, State or Local criminal justice agency/organization. I understand that a criminal history background check will be used to determine access to Tobyhanna Army Depot and that access to Tobyhanna Army Depot can be revoked at any time. PLEASE TAKE NOTICE THAT ONE OR MORE CRIMINAL BACKGROUND REPORTS PURSUANT TO THE FAIR CREDIT REPORTING ACT, AS AMENDED, 15 U.S.C. 1681 ET SEQ, MAY BE OBTAINED FOR THE PURPOSES OF ACCESS TO TOBYHANNA ARMY DEPOT. SHOULD A DECISION TO DENY ACCESS BE MADE BASED EITHER IN PART OR IN WHOLE ON THAT REPORT, THE REPORTING AGENCY THAT PROVIDED THE INFORMATION PLAYED NO ROLE IN THE DECISION.
Information provided by you on this form will be furnished to Tobyhanna Army Depot's Security Branch to obtain information in connection with an investigation to determine access to Tobyhanna Army Depot. This information is collected for national security and force protection purposes. Use of this form does not relieve