Elty Form 648 C PDF Details

The Elty 648 C form serves as a comprehensive request for access to the Tobyhanna Army Depot, aligning with the "Directive Type Memorandum (DTM) 09-012 Interim Policy Guidance for DoD Physical Access Control" dated April 22, 2014. This document is meticulously designed to strengthen force protection measures for all non-DoD credentialed individuals seeking entrance to the installation. It encompasses vital sections including a PRIVACY ACT STATEMENT, which clarifies the authority, principal purpose, routine uses, and the voluntary nature of disclosures, highlighting the consequences of non-compliance. Applicants are required to furnish detailed personal information, anticipate the purpose of their visit, and undergo a criminal history background check as part of the access determination process. Furthermore, the form extends into sensitive areas, probing into the applicant's possible criminal background, current or past military disciplinary actions, citizenship status, and any existing security clearances by the U.S government. A unique segment obligates the applicant to certify the truthfulness and completeness of the information provided under penalty of potential denial, revocation of access, or legal ramifications. This document signifies a rigorous vetting process emphasizing national security and force protection, ensuring that only properly examined individuals gain access to the critical operational environments of the Tobyhanna Army Depot.

QuestionAnswer
Form NameElty Form 648 C
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names648 form, form tlty 648 c, 648 c, form n648

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Request for Access to Tobyhanna Army Depot

Use in accordance with " Directive Type Memorandum (DTM)" 09-012 " Interim Policy Guidance for DoD Physical Access Control" dated 22 Apr 14

Proponent Office is ELTY-ISR-S

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 United States Code, Section 3013

PRINCIPAL PURPOSE(S): In conjunction with "Directive Type Memorandum (DTM)" 09-012 "Interim Policy Guidance for DoD Physical Access Control", dated 22 Apr 14, this form is intended to ensure that force protection measures are implemented for all non-DoD - credentialed personnel who request access to the installation.

ROUTINE USES: To control and maintain force protection requirements.

DISCLOSURES: Voluntary civilian. Failure to provide information deemed "mandatory" may result in a processing delay of your request for access or a denial of your request.

Application Date

Date of Anticipated Visit or Yellow Contractor Badge Expiration Date

Areas of TYAD to be Visited

 

Reason for Request for Criminal History Background Check

Please check one of the following options

 

Yellow Contractor Badge

Access to Installation

 

 

 

 

 

 

 

 

 

First Name

 

Middle Name

 

Last Name

 

 

 

 

 

 

Other Names Used

Street Address

City

State

Zip Code

Home Telephone Number

Sex

Race

Country Place of Birth

State Place of Birth

(If not born within the U.S.) Provide U.S. Passport, Green Card, or Naturalization Certificate

Date of Birth:

Social Security Number

Driver's License State of Issurance

Driver's License Number

Tobyhanna Federal Employee POC

Tobyhanna Federal Employee POC Phone Number

Tobyhanna Federal Employee POC Directorate

Tobyhanna Federal Employee Point of Contact E-mail Address

This Area To Be Completed Only If You Are A Contractor or Vendor

Name Of Company (No Abbreviations)

Company POC

Company Address

City

State

Zip Code

Company POC Phone Number

Company POC Fax Number

Company POC Email address

CRIMINAL HISTORY BACKGROUND CHECK RELEASE AND CONSENT

I hereby authorize the Tobyhanna Army Depot Security Branch to receive any criminal history/background information pertaining to me which may be in the files of any Federal, State or Local criminal justice agency/organization. I understand that a criminal history background check will be used to determine access to Tobyhanna Army Depot and that access to Tobyhanna Army Depot can be revoked at any time.

PLEASE TAKE NOTICE THAT ONE OR MORE CRIMINAL BACKGROUND REPORTS PURSUANT TO THE FAIR CREDIT REPORTING ACT, AS AMENDED, 15 U.S.C. 1681 ET SEQ, MAY BE OBTAINED FOR THE PURPOSES OF ACCESS TO TOBYHANNA ARMY DEPOT. SHOULD A DECISION TO DENY ACCESS BE MADE BASED EITHER IN PART OR IN WHOLE ON THAT REPORT, THE REPORTING AGENCY THAT PROVIDED THE INFORMATION PLAYED NO ROLE IN THE DECISION.

Information provided by you on this form will be furnished to Tobyhanna Army Depot's Security Branch to obtain information in connection with an investigation to determine access to Tobyhanna Army Depot. This information is collected for national security and force protection purposes. Use of this form does not relieve any contractor of any requirement to perform a criminal background check or drug test.

ELTY FORM 648-C, DEC 2014

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Please answer the following questions and report information truthfully; regardless of whether your case has been "sealed", expunged or otherwise stricken from the court record. The single exception to this requirement is certain convictions under the Federal Controlled Substances Act-cases for which the court has issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607.

If the answer is "yes" to any of these questions, please list the actual offense or violation (for example: theft, DUI, battery, etc).

1. Are you currently barred from ANY military installation?

YES NO

If YES, for what offense (s)?

 

 

2. Have you ever been arrested for, charged with, or convicted of a sex offense? Are you a registered sex offender?

If YES, list the offense, date and jurisdiction.DateJurisdiction Offense

3. Have you ever been charged with or convicted of a felony?

Date

Jurisdiction

If YES, list the offense, date and jurisdiction.

 

 

Offense

 

 

4. Have you ever been charged with or convicted of a firearms, weapons, or explosives offense?

If YES, list the offense, date and jurisdiction.DateJurisdiction Offense

5. Have you ever been charged with or convicted of any offense related to alcohol or drugs?

If YES, list the offense, date and jurisdiction.DateJurisdiction Offense

6. In the last 7 years, have you been subject to a court martial or other disciplinary proceedings under the Uniform Code of

Military Justice? (Include non-judical, Captains's mast, etc.)

*If YES, list the offense, date and jurisdiction.

Offense

Date

Jurisdiction

 

 

7. In the last 10 years, have you been arrested for, charged with, or convicted of any other offense not listed above? ( Include

misdemeanors) Leave out traffic fines of less than $150 unless the violation was alcohol or drug related. If YES, list the

offense, date and jurisdiction.DateJurisdiction Offense date

8. Are you currently on parole or probation? If YES, for what offense(s)?

9. Are you a United States Citizen?

If no, please list your country of citizenship, registration number, and the expiration date of your work permit.

Country of Citizenship

Registration Number

Expiration of your work permit

 

 

 

 

 

 

 

 

10. Do you currently have or have you ever been issued a security clearance by the United States government?

If yes, please provide details on where the clearance was issued and the status of the clearance. A Tobyhanna government issued badge is not a security clearance.

Clearance Issued

Status of Clearance

APPLICANT CERTIFICATION

I certify that, to the best of my knowledge and belief, all of the information provided on this request for access to Tobyhanna Army Depot is true, correct, complete and made in good faith. I understand that false, fraudulent, or incomplete information may be grounds for the denial of my request or for the revocation of access to Tobyhanna Army Depot and may be punishable by fine or imprisonment. I understand that any information I provide may be investigated.

Name of Applicant (Print):_____________________________________

Date:__________________

Signature:__________________________________

ELTY FORM 648-C, Dec 2014

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form n 648 2019 completion process outlined (stage 1)

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form n 648 2019 writing process detailed (portion 5)

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