Current Badge Expiration:________ Addition/Revision

ASG-QA BADGE REQUEST

OTHER COUNTRY NATIONAL (OCN) EMPLOYEES PRIVILEGE & ACCESS JUSTIFICATION FORM (1 of 2 pages)

SECTION 1: To be completed by Supervisor of Organization (ALL AREAS MUST BE FILLED IN)

(Failure to properly fill out this form will result in rejection of request)

1) U.S. ORGANIZATION REQUESTING PRIVILEGE/ACCESS: ,

A) COR requesting OCN Privilege/Access: (Name, Rank, Bldg #):_____________________________________

B) COR Phone DSN Number/Cell:___________________ Email:

2) COMPANY NAME (INCLUDING ALL SUBCONTRACTS):

A) Supervisor Name and Phone #:

B) Contract Number and Contract End Date:

3) OCN EMPLOYEE’S NAME (Last, First, Middle):

A) Nationality: Filipino

B) Date of Birth: Place of Birth:

C) Passport Number:_________________________ Previous Passport #__________________________________

D) Passport issued by (Country): _____________Date of Issue:___________ Date of Expiration:________________

E) OCN Phone Number (NOT the supervisor’s or CAS number): Cell:_____________ Residence:_____________

4) JOB TITLE AND DESCRIPTION (OCN Employees): ____________________________ Time on CAS:_________

5) WORK LOCATION(S), PER LOA: CAS: ____Falcon 78: ____CAS South: ____

A) Building Numbers:_______________________________ Work Areas:___________________________________

6) REQUEST ADDITIONAL PRIVILEGES AS STATED IN LOA :

*NOTE: MARK REQUEST(S) WITH AN X AND ATTACH LOA

DFAC____ Mil Exchange____ Mil Banking____ Post Office____ CAC____
MWR Sites: PX__ Barber/Beauty Shop___ Gyms___ Trips___ Oasis/TopOff___

7) REQUESTED UNESCORTED PRIVILEGE (Red Badge): Yes_____ No_____ Justification: __________________

8) REQUEST ESCORT PRIVILEGE OCN: YES___ NO___

(Must Provide Justification Memo with Badge Request Packet and on Date of Training)

9) REQUEST CELL PHONE PRIVILEGES: YES___ NO___

(Needs Installation Commanders Approval)

Cell Phone Make/Model: Cell Phone Number: N/A

SIM Card Number: N/A IMEI: ______________________________

10) REQUEST POV DRIVING PRIVILEGE ON CAS: Yes NO

(Needs Installation Commanders Approval)

Vehicle ID: License plate number:

BADGE EXP: NBP:

Current Badge Expiration:________ Addition/Revision
ASG-QA BADGE REQUEST

OTHER COUNTRY NATIONAL EMPLOYEES PRIVILEGE & ACCESS JUSTIFICATION FORM (2 of 2 pages)

SECTION 2: (ALL AREAS MUST BE FILLED IN)

OCN EMPLOYEES NAME:

*NOTE: Must be the same name located on page 1*

11) REQUEST MAGNETIC MEDIA PRIVILEGE ON CAS: Yes NO

(Needs Installation Commanders Approval)
Make/Model Serial number:

12) DIRECTORATE /COR Approval Name (Print): ________________________________________________

Date: Approval Signature: ______________________

DD-MMM-YY
SECTION 3: To be completed by Screening Office

Name and Background Checks: Derogatory / No Derogatory Escort Privileges Verified Yes / No

Screener Signature: ___________________________Date:____________

Screener Comments: _____________________________________________________________________

______________________________________________________________________________________

SECTION 4: To be completed by PMO

Name and Bar List derogatory checks: Derogatory / No Derogatory

PM or Designee Signature: _______________________________Date: _____________

OCN Employees will be issue /granted privileges shown on back of DBIDS Card
(DBIDS/PMO AUTHORIZED PERSONNEL ONLY)

//////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////
*All packets that require Exception to Policy must be approved and signed by Installation Commander.*

Installation Commander or Designee Signature: _______________________________Date:________

/////////////////////////////////// Document Supersedes all Previous 14 September 2015//////////////////////////////////