Fillable Business Pass Application printable pdf download

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Marine Corps Base, Camp Pendleton

BUSINESS PASS APPLICATION

PRIVACY ACT STATEMENT

AUTHORITY:10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; OPNAVINST 5530.14C, Navy Physical Security; Marine Corps Order P5530.14,

Marine Corps Physical Security Program Manual; and E.O. 9397 (SSN), as amended.

PRINCIPLE PURPOSE: To control physical access to DoD, Department of the Navy (DON) or U.S. Marine Corps Installations/ Units controlled information, installations, facilities, or

areas over which DoD, DON, or USMC has security responsibilities by identifying or verifying an individual through the use of biometric databases and associated date processing/

information services for designated populations for purposes of protecting U.S./Coalition/ allied government/ national security areas of responsibility and information; to issue badges,

replace lost badges and retrieve passes upon separation; to maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/ exit times of personnel.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records contained therein may specifically be disclosed

outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: To designated contractors, Federal agencies, and foreign governments for the purpose of granting Navy

officials access to their facility.

DISCLOSURE: Disclosure of this information is voluntary; however, failure to provide the requested information will result in denial of a Business Pass.

RESTRICTIONS/ INSTRUCTIONS: Base Business Passes may only be used by person to whom they are issued, and for the specific business/ purpose issued. Applicants are reminded

that soliciting (i.e., door-to-door sales) is prohibited on the base, and that such activity is grounds for cancellation of the Pass. Additionally, such action may result in debarment from the

base and legal action. Business Passes are issued for a maximum period of 90 days and must be renewed if the contract extends beyond that period. Please complete all information in

black ink (printed) or by typing. Allow 3-5 business days for processing.

Application Date

SSN

Last Name

First Name

Middle Initial

Home Address

City

State

ZIP Code

City of Birth

State of Birth

Country of Birth

Gender

Race

Date of Birth

Applicant Telephone

Employer Name

Employer Address

Employer City

Employer State

Employer ZIP Code

Employer Telephone

Base Sponsor

Primary Sponsor

Primary ID Type

Primary ID Number

Primary ID Jurisdiction

Secondary ID Jurisdiction

Secondary ID Type

Secondary ID Number

AUTHORIZATION FOR CRIMINAL HISTORY CHECK AND APPLICANT SIGNATURE/ AUTORIZACION PARA HISTORIAL CRIMINAL Y FIRMA

This form represents authorization to run a Criminal History Check. Autorizacion para llevar a cabo su Historial Criminal

I declare, under penalty of perjury, that the forgoing information is true and complete to the best of my knowledge. Declaro aqui, bajo penalidad de la ley, que la

informacion proporcionada es correcta a mi leal saber y entender.

Signature/Firma:_______________________________________________

Date/Fecha:______________

Expiration Date

Status

Entered in C/S System By

Pass Issue Date

Date to Dispatch

NCIC (III) CHECK PERFORMED BY:

RESULTS OF NCIC CHECK:

LOCAL RECORDS CHECK

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