PMRF Guest Card Application Form – Fill Out and Use This PDF

__New	Navy Region Hawaii - PMRF
__Renewal	MWR Guest Card Application

Please take your completed application, cash or check for $25.00, payable to MWR Fund, to the MWR Administration Office, Building 1267, Telephone 335-7936 OR Pass & ID Office, Building 1273. We will process your application & conduct a background check. Process takes about 2 - 3 weeks. Please call 335-7936 to check on the status. Thank you for your support of Morale, Welfare and Recreation.

APPLICANT INFORMATION

FIRST

MIDDLE

LAST NAME

SSN:

DATE OF BIRTH:

ADDRESS:

CITY:

STATE:

ZIP CODE:

TELEPHONE NUMBER:

CELL PHONE NUMBER:

E MAIL ADDRESS:

(

)

(

)

DRIVERS LICENSE NUMBER:

DRIVERS LICENSE – STATE:

U.S. CITIZEN:

YES

NO

VEHICLE INFORMATION

MAKE:	MODEL:		YR:	COLOR:
VEHICLE PLATE NO.	STATE:	INSURANCE CARRIER	POLICY NO.:

*IF VEHICLE IS NOT IN YOUR NAME, A NOTORIZED LETTER OF AUTHORIZATION IS REQUIRED!

NAVY REGION HAWAII USE ONLY

I verify that the Applicant information above is correct.

Signature of Verifier (Navy Region Hawaii Representative)	Date:

APPLICANT’S STATEMENT AND SIGNATURE

I AGREE TO OBEY ALL RULES AND REGULATIONS OF NAVY REGION HAWAII. AS A CONDITION OF ENTRY, I CONSENT TO ANY INSPECTION AND SEARCH OF MY PERSON, PROPERTY OR VEHICLE. I AM AWARE OF AND WILL COMPLY WITH THE RULES PROHIBITING THE INTRODUCTION OF LIQUOR, DRUGS OR ANY TYPES OF WEAPON ONTO ANY INSTALLATION. I ASSUME ALL RISKS FOR PERSONAL LOSS, DAMAGE OR INJURY OF ANY NATURE TO MYSELF OR U.S. GOVERNMENT PROPERTY WHILE ON BASE. I UNDERSTAND THIS PASS IF FOR MY PERSONAL USE AND CANNOT BE TRANSFERRED. NO GUESTS AUTHORIZED.

I CERTIFY THAT I AM A CITIZEN OF THE UNITED STATES OF AMERICA. I ACKNOWLEDGE A NATIONAL AND LOCAL AGENCY CHECK WILL BE PERFORMED.

PRIVACY ACT STATEMENT: This record contains personal information concerning the civilian personnel who may be granted access to a Government installation for the purposes of using Morale, Welfare and Recreation facilities. Authority to obtain, use and disclose information is governed by 5 U.S.C. ss. 552.A and SECNAVINST 5211.5D. Disclosure of this information is “voluntary”, however, failure to provide the requested information could result in denial of access authority.

I CERTIFY THAT ALL INFORMATION PROVIDED IS CORRECT

MWR GUEST CARD

Authorization to Conduct Background Investigations

In accordance with the Privacy Act of 1974, I have been provided with a copy of a statement advising me that certain information is required to assist Navy Region Hawaii in making a security determination concerning me and that the execution of this form is voluntary.

I hereby authorize and consent to the release of information and records bearing on my personal history, arrests and convictions, if any, to background investigation and/or criminal justice agency and its subsidiaries, affiliates, officers, agents and employees, the Morale, Welfare and Recreation Department and Navy Region Hawaii. The information will be used for the sole purpose of determining my access to Navy Region Hawaii, Morale, Welfare and Recreation facilities.

This authorization is valid for one year after my signing. Upon request, a copy of this signed statement may be furnished to the criminal justice agency or other person furnishing such information or record.

Print Name: ________________________________________________________				Male	Female
First Name	Middle Name		Last Name
Print former name (maiden name) if applicable:____________________________________
(Name change through marriage or otherwise)
Current Street Address:____________________________________________________________
City: ___________________________		State: ________ Zip Code: ________________

List previous residences (going back 2 years only).

City: ___________________________ State: ________ County: __________________

City: ___________________________ State: ________ County: __________________

Phone Numbers: ________________________ (home) ___________________________ (work)

Date of Birth (for identification purposes only) _______________________________________

Social Security Number (for identification purposes only) _____________________________

XSignature: ____________________________________ Date: ________________________

THERE IS A $25.00 CHARGE FOR THE NATIONAL BACKGROUND CHECK. (NONREFUNDABLE) PLEASE SUBMIT CASH OR CHECK PAYABLE TO MWR FUND FOR THE TOTAL COST.

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Payment amount: $________ Date Payment Received:__________ Circl e One : Check Cash

Receipt # ___________ Recei ved by__________________________________________________________

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