Employee Base Pass Request

EMPLOYEE BASE PASS REQUEST

Use this form to request issuance, renewal, or replacement of an employee base access pass. Completion of this form authorizes verification of identity, employment, and background screening as required for access authorization. Provide complete and accurate information. Incomplete or false statements may result in denial or revocation of access privileges and may be subject to disciplinary action.

Personal Information

Date of Birth:    Place of Birth:

Position Information

Reporting Manager:    Employment Start Date:

New issuance    Renewal    Replacement (lost/damaged)

Unescorted base access    Escorted access only    Temporary/limited access

Vehicle Information (if vehicle decal requested)

License Plate Number:    State of Registration:

Identification Documents Provided

Driver's License    Number:

Passport    Number:

State ID    Number:

Employment History (Most Recent)

Title:    Dates Employed:

Employment History (Previous)

Title:    Dates Employed:

Education

Graduation Date:

References

Legal Disclosures and Authorizations

At-Will Employment: Employee acknowledges that issuance of a base pass does not alter the at-will nature of employment and that employment may be terminated at the option of either the employee or the employer consistent with applicable law.

Equal Opportunity: Access authorization and employment decisions are made without regard to race, color, religion, sex, national origin, age, disability, genetic information, or other protected characteristics as required by law.

Background Check Authorization: I authorize the employer, its agents, and authorized security officials to obtain records and investigative information about me to verify information provided on this form and to conduct criminal records, employment, education, and identity verification as required for access. I understand that access may be denied or revoked based on results of required screening.

Privacy and Use of Information: Information provided on this form will be used to determine eligibility for base access and for recordkeeping, audit, and security purposes. Disclosure of requested information is voluntary but failure to provide required information may result in denial of access.

Certification: I certify that all information provided on this form is true, complete, and correct to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information may disqualify me from access and may subject me to disciplinary or legal action. I authorize the verification of any and all statements herein.

I further consent to fingerprinting or other biometric collection if required by security authorities for identity verification and background screening.

I acknowledge and consent to the statements above and authorize verification and background checks as necessary.

Applicant Certification

I certify under penalty of perjury that the foregoing is true and correct. I understand that approval of this request is contingent upon completion of required verifications and approval by authorized security personnel. I agree to comply with all applicable base entry, parking, and security procedures while holding a base pass.

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