REQUEST FOR A FORT RUCKER VISITOR ACCESS CARD (Unsponsored)
PRIVACY ACT STATEMENT
AUTHORITIES: Executive Orders (EO) 10450, 10865, and 12333. The SSN, required for record accuracy, is requested pursuant to EO 9397.
PRINCIPAL PURPOSE(s): To collect identifying information on non-DoD visitors and contractors requesting unescorted access to the Installation.
ROUTINE USE(S): To perform NCIC-III Background Check for Installation Access.
DISCLOSURE: Although disclosure of your SSN is not mandatory, failure to disclose your SSN will prevent the processing of your background check.
1. APPLICANT INFORMATION:
Last Name: ____________________________ First Name: ____________________ Middle Initial: _________
SSN: __________________ DOB: ____________ Race: _____________
Sex: ________ Height: _________ Weight: ________ Eye Color: __________ Hair Color: _______________
Driver's License # ___________________________________
State Issuing DL: ________________________
Phone Number: ___________________________
2. REASON FOR CARD:
____ Non-DoD Contractor
____ Family Care Provider
____ Visiting Family/Friends
____ Gold Star Family
____ DFMWR Patron
____ Other: ______________________________________________________________________________
Date(s) for Expected Visit / Length of Contract:____________________________________________________
Requested Duration: ___ 1-7 Days
___ 8-180 Days ___ Other: ___________________________________
3. JUSTIFICATION FOR CARD: _______________________________________________________________
4. Applicant Certification:
I certify the information provided is true and accurate, and I am providing it with the purpose of receiving a Fort Rucker
Visitor Access Card to allow access onto Fort Rucker. I understand I must give Fort Rucker Visitor Control Centers
consent to conduct a criminal history screening prior to the issuance of a Visitor Access Card. Failure to do so will result
in the termination of the application process. I understand that this background screening will determine my eligibility for
access and continued access during the term of my visit. I understand that I am required to turn in the card upon
expiration or prior to expiration if I no longer require it. If I fail to do so, my access to Fort Rucker may be denied for any
and all future requests. I understand my access may be revoked at anytime without reason or notice. I understand it is
prohibited to allow someone else to use my Visitor Access Card.
Applicant Printed Name
SECTION BELOW IS FOR USE BY THE VISITOR CONTROL CENTER OFFICE ONLY
5. ISSUING OFFICIAL: Approved / Disapproved
Date of NCIC-III check: ____________________
Issue Date: _______________ Expiration Date: _______________
Issuing Official Printed Name
Issuing Official Signature
Fort Rucker Form 2746-R-E, APR 2015