Fort Lee Form 190-3 - Request For Unescorted Installation Access To Fort Lee

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REQUEST FOR UNESCORTED INSTALLATION ACCESS TO FORT LEE
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY: Title 5, USC 3331, 552, 552a; 10 USC 10204; Executive Orders (EO) 10450, 10865, and 12333.
PRINCIPAL PURPOSE: The information requested is for the purpose of granting access to the Fort Lee Installation.
ROUTINE USES: Basis for determination of qualifications and background information for eligibility for access to Fort Lee Installation. The Social
Security Number (SSN), required for record accuracy, is requested pursuant to EO 9397.
DISCLOSURE: Providing requested information, to include your SSN is voluntary. However, your access may not be granted if all requested
information is not provided. Contents shall not be disclosed, discussed, or shared with individuals unless they have a direct need-to-know in
performance of their official duties. Deliver this document directly to the intended recipient. DO NOT drop off or send to a third-party. This
document contains personal or privileged information and should be treated as "For Official Use Only (FOUO)".
PART I - APPLICANT INFORMATION
a. LAST NAME:
b. FIRST NAME:
c. MIDDLE INITIAL:
d. GRADE/RANK/STATUS:
e. SOCIAL SECURITY NUMBER:
f. DOB:
g. GENDER:
Male
Female
h. E-MAIL ADDRESS:
i. PHONE NUMBER :
j. EMPLOYER:
Exp Date .
RACE:
k. DRIVER'S LICENSE / ID #
STATE:
PART II - VISITOR (N/A FOR CONTRACTORS/SUPPORT PERSONNEL)
a. REQUESTED DATE(S) / TIME OF VISIT: FROM
TO
b. PURPOSE OF YOUR VISIT:
GRADUATION
MUSEUM
VISIT FAMILY
GOLF/BOWLING
SPECIAL EVENT (Specify below):
PART III - VEHICLE
a. MAKE:
b. MODEL:
c. COLOR:
d. PLATE #:
PART IV - CONTACT/SUPPORT PERSONNEL
a. CONTRACT/GOVERNMENT BILL OF LADING #:
b. GOVERNMENT ORGANIZATION/BUSINESS SUPPORTED:
c. CONTRACT EXPIRES:
d. COR/SUPERVISOR:
PART V - GOVERNMENT SPONSOR'S CERTIFICATION
I certify that the applicant meets the justification requirements as indicated in Part IV above for access privileges.
Furthermore, I certify that the applicant requires an access control card as indicated above in order to perform
assigned duties or conduct official business on Fort Lee.
a. COR/SUPERVISOR/PHONE NUMBER
b. SUPERVISOR/SPONSOR SIGNATURE
(Invalid if Incomplete)
(Invalid if Incomplete)
PART VI - ISSUING OFFICE
SECTION BELOW IS FOR USE BY INSTALLATION ACCESS CONTROL OFFICE ONLY
a.
APPROVED
b.
DISAPPROVED
c.
ACTION TAKEN (Specify below)
a. APPROVING OFFICIAL PRINTED NAME
b. APPROVING OFFICIAL SIGNATURE
DATE
FORT LEE FORM 190-3, JAN 2015
PAGE 1 OF 2

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