Form 2746-R-E - Request For A Fort Rucker Visitor Access Card (Unsponsored)
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1REQUEST 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: _____________
Ethnicity: ___________________
Sex: ________ Height: _________ Weight: ________ Eye Color: __________ Hair Color: _______________
Driver's License # ___________________________________
State Issuing DL: ________________________
Phone Number: ___________________________
2. REASON FOR CARD:
____ Non-DoD Contractor
____ Vendor
____ 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
Applicant Signature
Date
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
Date
Fort Rucker Form 2746-R-E, APR 2015
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