Friends Of K-Bay Application Form - Marine Corps Community Services Hawaii
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1Office Use Only: RecTrac/HSI Receipt # __________
“FRIENDS OF K-BAY APPLICATION FORM”
Revised:
April 2013
Attach Copies of Vehicle Registration, Vehicle Safety, Hawaii No Fault insurance, Driver’s License, and $10 processing fee .
Request the following “Friends of K-Bay” be authorized an Installation Access Pass.
The duration of this FOKB Installation Access Pass is for a maximum of one year from date of approval.
This FOKB access pass is for this applicant ONLY.A $10 processing fee is required (effective 1 May 2013).
MCCS Facility Participation(Please mark one):
Klipper Golf Course
K-Bay Lanes
Officers’ Club
Name of MCCS Manager/Supervisor/Sponsor
Rank/Title
Name of Activity
Signature
Date
Phone number
MCCS ACTIVITY IS RESPONSIBLE FOR ALL THE ACTIONS OF THE FRIENDS OF
K-BAY PASS HOLDER WHILE ONBOARD MARINE CORPS BASE HAWAII, KANEOHE BAY
Guest Information
Name of Sponsored Guest (Last, First MI)
HI DL # OR SSN
Date of Birth,
Height, Weight, Color Hair, Color Eyes
Address (Include City, State and Zip Code)
/
/
/
/
Home Phone
Cell Phone
Signature
Email Address
May we use your email address to
Statement of Understanding:
By signing this
pass application, I agree to the terms and conditions stated
contact you for information and to update you on
herein and will abide by Marine Corps regulations while on
current events and volunteer opportunities?
Marine Corps Base Hawaii.
Furthermore, I agree that I am in
good standing with the United States Marine Corps and have
YES
never been banned from any military installation.
NO
Email:________________________________
SIGNATURE:_____________________________ DATE:_________
Vehicle make
Model
Color
Vehicle VIN #
/
/
Vehicle State registration # (License Plate number)
Drivers License: State,
Number,
Expiration
Hawaii No Fault Insurance Carrier and Policy Number:
Military Police Department Records Check
Rank/Name
Date
Signature
Approved by MCCS
Rank/Name
Date
Signature
ACKNOWLEDGEMENT
This access pass is not transferable and authorized access to Marine Corps Base Hawaii only.
The applicant agrees to
comply with Federal/DOD guidelines and to consent to a local records check.
Acknowledgement of this form provides Marine
Corps Base Hawaii permission to conduct a routine background check on the applicant.
I certify that the information on
this form is true and accurate to the best of my knowledge.
If the vehicle pass and identification card is lost or
stolen I will immediately report it to the Military Police Department, 257-2047.
PRIVACY ACT INFORMATION
Authority> Title 10, United States Code, Section 2012
Principal purpose: The purpose for requesting personal information is to verify identification of the applicant and to
assist civilian access on to Marine Corps Base Hawaii, Kaneohe Bay.
Routine Use: Information provided may be used to determine eligibility of applicants desiring access to Marine Corps Base
Hawaii, Kaneohe Bay as well as for other lawful purposes including law enforcement and litigation. For other official
purposes, information on this form may be provided to other law enforcement agencies. Disclosure: Submitting requested
information is voluntary, however, failure to provide information will result in access privileges being refused or
withdrawn. The Privacy Act Statement will apply throughout the duration of the access pass.
Official Use Only:
Date Rec’d & Paid For_________ Front Gate Drop-off __________ Front Gate Pick-Up:__________
Date Rec’d F&H Office __________ Date Mailed __________ Expiration Date________
Pass
Number:_________
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