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(THIS FORM IS SUBJECT TO THE PRIVACY ACT (Cochise College)

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FORT HUACHUCA ACCESS REQUEST FORM
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
ALL REQUEST MUST BE SUBMITTED IN PERSON TO THE VISITOR CONTROL CENTER
“IMPORTANT” REGARDING ACCESS DENIALS:
Please read Section 6 “Applicant Attestation”
Section 1. Applicant Information (Failure To Provide All Requested Information May Result In Denied Access)
Please select one:
US Visitor
Contractor
Foreign National
MILITARY:
Active Duty
Reservist
National Guard
1. FULL NAME (Last, First, Middle)
2. Driver’s license Number/ State
3. Social Security Number
4. Date of Birth (DD/MM/YYYY)
5. CURRENT RESIDENT ADDRESS (Include City/ State/ZIP Code)
6. HOME/ CELL PHONE NUMBER
WORK PHONE NUMBER
7. SEX
8. RACE
9. EYE COLOR
10. HAIR COLOR
11. HEIGHT
12. WEIGHT
13. PASSPORT NUMBER:
14. PASSPORT COUNTRY
Section 2. Place of Birth
1. U.S. Citizen?
2. U.S. RESIDENT?
3. LIST IMMIGRATION DOCUMENT TITLE, DUCUMENT NUMBER
4. EXPIRATION DATE
YES NO YES NO
5. CITY
6. STATE (If applicable)
7. COUNTRY
Section 3. Purpose of Visit
Purpose
(Specify):___________________________________________________________________________
Location
:_____________________________
* Date(s) of visit Requested//
From Date: _______________________
To Date: ________________________
Number of Days: ____________
Section 4. Military Personnel Information
1. Unit Name (Regiment, Battalion, Company and unit number, etc.)
2. Unit Phone Number (Unit Leadership)
3. Unit Location (Street Name, Bldg. Number if possible)
4. MOS
5. Job Description
Section 5. CONTRACTOR/VENDOR INFORMATION (IF APPLICABLE)
The following company/organization is providing either vendor’s service or holds a
contract with our organization. The individual is required to enter Fort Huachuca, AZ in an official capacity on a regular basis.
2. Company/ Organization Name
2. Company/ Organization Phone Number
3. Job Description
Section 6. Applicant Attestation
I understand that I must give Fort Huachuca Visitor Control Center (VCC) consent to an initial criminal history and periodic background screenings though the National
Crime and Information Center (NCIC) prior to and after the issuance of an installation car/pass by completing the FORT HUACHUCA ACCESS REQUEST FORM. Failure
to do so will result in termination of the application process. I further understand that these background screenings will determine my eligibility for access and
continued access during the term of my visit. I understand (a) criminal offense(s) may be prosecuted in federal court. The information I have provided on this
application is true, complete, and correct to the best of my knowledge and belief, and is provided in good faith. I understand that a knowing and willfully false
statement on this application can be punished by fine or imprisonment or both (18 U.S.C section 1001). If denied, you may appeal in writing to the Garrison
Commander in accordance with the instructions in the access denial packet given by the VCC; ATTN: Physical Security
a. I understand that my access may be revoked at any time without reason or notice.
b. I understand that I must properly care for my card/pass to prevent damage, or loss.
c. I understand that it is prohibited to allow someone else to use my card/pass.
d. I understand that my card/pass must be turned in to the VCC once it has expired or further use is not required.
Applicant Signature: ___________________________________________________________ Date: _________________________________
Section 7. Government Sponsor / Authorizing Information (If Applicable)
Upon termination of contract, employee termination, or
expiration of the access credential the Authorizing Official will retrieve the credential from the contractor and return it to buildings 90008/Buffalo Soldier Gate or
90790/Van Deman Gate. The Government Sponsor must complete their portion before it is accepted at the Visitor Control Center (VCC). Being a sponsor you assume
all responsibility for your visitor while they are on the installation.
1. Full Name (Last, First, Middle)
2. Official Title
3. Organization
4. Work Phone Number
5. Official Email Address
THE SPONSOR AGREES TO ACCEPT RESPONSIBILITY FOR THEIR VISITOR(S) WHILE ON THE INSTALLATION:
Sponsor’s Signature: _____________________________________ Date: ___________________
Section 8. Issuing Office
(Section Below is for use by Installation Access Control Office Only)
Approved for: 1 Day / 30 Day / 1 Year / Dual Res / Escort required
Disapproved
DENIAL
WARRANT
FBI#___________________
Approving Official Printed Name
Approving Official Signature
Date
INSTALLATION ACCESS REQUEST FORM, JAN 2018
(DIRECTORATE OF EMERGENCY SERVICES)
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(THIS FORM IS SUBJECT TO THE PRIVACY ACT (Cochise College)

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Completed 25 July 2020

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