Ae Form 190 16a

A. Organization and telephone number c. Signature b. Name and title 27. To be completed by registrar a. Registrar name AE FORM 190-16A MAR 05 b. However failure to provide any item of information will result in denial of entry onto the U.S.-controlled installations for which the AE Form 190-16A has been validated. Please refer to the instructions on page 3 to ensure that the form is correctly filled in. 1. Some installation-pass applications may include a copy of Residence permit Defense Clearance Investigation Index DCII Proof of AE Form 604-1A Foreign National Screening FNS initiation/completion Police Good Conduct Certificate PGCC Polizeiliches F hrungszeugnis Military police MP check results Instructions for completing AE Form 190-16A Item 1. APPLICATION FOR USAREUR/USAFE INSTALLATION PASS AE Reg 190-16 Data required by the Privacy Act of 1974 Authority Article 53 Supplementary Agreement to NATO SOFA 10 USC 3012. Principal purpose s For identification of U*S* and non-U*S* nationals employed by U*S* Government agencies contractors and vendors of non-military agencies of countries in which U*S* personnel have been accommodated when these personnel require recurring access to the accommodations under U*S* control and do not possess other valid entry authorization documents. Routine use s To identify personnel authorized routine or recurring access to installations under U*S* control* Mandatory or voluntary disclosure and effect on individual not providing information Voluntary. To 2. From 4. Applicant name Last first MI 5. Sponsor address 6. Address Company/Organization/Unit 7. Person category 8. Country of citizenship 9. SSN/Personal ID number 10. Supporting document expiration date 11. Residence permit Yes No 12. Work permit Passport/ID card mm/dd/yyyy 13. Type pass requested Installation pass Temporary installation pass 3. Date mm/dd/yyyy 14. Date of birth mm/dd/yyyy 15. Weight Pounds 16. Height Inches 17. Eye Color 18. Hair Color 19. Installations for which access is required 20. Limitations/time/day access is required 21. FPCON restriction 23. Sign-in privileges IACO REGISTRAR MUST VALIDATE 22. Pass expiration date mm/dd/yyyy 24. Privately owned vehicle POV registration information additional vehicles may be added on a separate sheet of paper a* License number b. Country c* Make d. Model e. Year f* Body type g. Color 25. Company name and telephone number 26. Verification by sponsoring official must check both boxes I have reviewed the results of all background checks required by AE Reg 190-16 and verify that there is no derogatory information that would preclude the issuing of an installation pass. I verify that the applicant has been informed about the purpose and proper use of the installation pass. I have reviewed requirements. However if there is a problem or you need further information please contact me. Date issued Previous editions are obsolete. Page 1 of 3 pages Required attachments Check applicable boxes Requirements may be different depending on the person category selected* All installation-pass applications must include supporting documents.