10 YTPM 24-0005 439AW FORM 1_Blank.pdf

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oscar1970 11.0.1.20130826.2.901444

PHONE NUMBER

APPLICATION FOR 439 AW DBIDS IDENTIFICATION CREDENTIAL

PRIVACY STATEMENT

PRINCIPAL PURPOSE: Preliminary background check for a DBIDS identification card for unescorted installation access.

AUTHORITY: 10 U.S.C. 8012; 44 U.S.C. 3101, AWI 31-113, Installation Access Control, EO 9397

HAIR

NO

YES

SECTION II - APPLICATION ACKNOWLEDGEMENT

I hereby authorize the use of and release of my personal information to the 439th Security Forces Squadron to accomplish criminal background checks to determine eligibility for unescorted access to Westover ARB. I will promptly return all credentials when they are no longer needed for my assigned duties or upon request by proper authority.

SIGNATURE

COMPANY/ORGANIZATION

DATE (DD/MM/YYYY)

SECTION III - CERTIFICATE OF REQUESTING OFFICIAL

TITLE

SIGNATURE

SECTION IV - CREDENTIAL INFORMATION

I certify that the applicant has an official/authorized need for the credential requested and has been briefed on its proper use.

DAYS OF THE WEEK AND HOURS REQUESTING AUTHORIZATION TO ENTER WESTOVER ARB (Check all that apply) Sunday Wednesday Thursday Friday Saturday Tuesday Monday

DEPARTURE HOUR:

ENTRY HOUR:

CREDENTIAL EXPIRATION DATE

CONTRACT COMPLETION DATE

CONTRACT NUMBER

REMARKS

CREDENTIAL ISSUE DATE

CREDENTIAL EXPIRATION DATE

SIGNATURE OF ISSUING OFFICIAL

DATE (DD/MM/YYYY)

ESCORT PRIVILEGES (Check One) FPCON LEVEL ACCESS (Check One)

DELTA

CHARLIE

BRAVO

ALPHA

BACKGROUND CHECK COMPLETION DATE

NO

YES

ESCORT LIMIT:

EYES

SECTION V - VCC USE ONLY

DISCLOSURE: Disclosure is voluntary. Failure to provide requested information could result in restriction or non-access to Westover ARB. This data collection will not become part of any Privacy Act System of Record. This information will not be released outside of the DoD.

APPLICANT CATEGORY (X appropriate box - one only) HOME ADDRESS (Street, City, State and Zip Code)

SOCIAL SECURITY NUMBER

HAVE YOU EVER BEEN CONVICTED OF A FELONY?

IF YES, EXPLAIN:

DRIVER'S LICENSE/ID NUMBER

STATE OF ISSUE

LICENSE EXPIRATION

YES

NO

ARE YOU A UNITED STATES CITIZEN?

LONG TERM VISITOR

CONTRACTOR

VOLUNTEER

DOD CIVILIAN

ROUTINE USES: Provide information to assist in completing a background check of those individuals requiring access to Westover ARB. Once completely filled in and signed, the requesting official must send it encrypted to 439SFS.VCC@us.af.mil or hand deliver to 439 SFS Visitor Control Center/Building 5310.

SECTION I - APPLICANT

LAST NAME / SUFFIX

FIRST NAME

DOB (DD/MM/YYYY)

HEIGHT

WEIGHT

MIDDLE NAME

OTHER:

NAME (First, Middle Initial, Last)

ORGANIZATION

PHONE NUMBER

DATE (DD/MM/YYYY)

AW FORM 1, 20160926

INSTRUCTIONS FOR COMPLETING

APPLICATION FOR 439 AW DBIDS IDENTIFICATION CREDENTIAL

Use this form to:

1. Request DBIDS Contractor ID. Individual with a valid need requiring issuance of a Defense Biometric Identification Database System (DBIDS) credential for unescorted entry to Westover Air Reserve Base. This form is also used to conduct background checks prior to installation entry for sub-contractors under escort of a contractor granted escort authority.

2. Request DBIDS Long Term Visitor ID. Individuals with a valid need requiring access to the installation for greater than 60 days. These individuals must be sponsored by either Active, Guard, and Reserve military/retired personnel, their spouses, or their children 16 years or older, or DoD Civilians who currently reside on Westover ARB.

3. Request DBIDS DoD Civilian ID. Civilian retirees and their eligible dependents who have been authorized installation access for limited use of MWR facilities by the 439th Airlift Wing Commander.

4. Request DBIDS Volunteer ID. Community Partner members who have been granted unescorted access to Westover ARB at the request of the installation commander.

5. Other. This category is used for any category not listed.

6. Governing guidance is in 439th Airlift Wing Instruction 31-113, Installation Access Control

SECTION I.

(Completed by Applicant) The Applicant will enter the requested information for every block. If unsure of any block, contact the Requesting Official for assistance.

Mark X in the appropriate category that you fall under, Contractor, Long Term Visitor, DOD Civilian, Volunteer, or Other (must specify).

If there is a past felony conviction enter the date and reason.

SECTION II.

(Completed by Applicant) The Applicant acknowledges the statement, enters the company or organization, date, and manually or digitally signs.

SECTION III.

(Completed by Requesting Official) The Requesting Official acknowledges the statement, enters all require information, and manually or digitally signs.

SECTION IV.

(Completed by Requesting Official) The Requesting Official will enter the requested information for every block.

The contract number is required for tracking and accountability.

Provide an estimated contract completion date. The requested credential expiration date will not extend past the contract completion date.

The Requesting Official will use the remarks section to include any other pertinent, applicable information. (e.g., Applicant is including an attached AW Form 2 authorizing escort authority for 1 individual).

SECTION V.

(Completed by 439 SFS/S5V) The 439th SFS/Visitor Control Center personnel will enter the FPCON level access is allowed. The level will be derived from Westover ARB, MA Integrated Defense Plan 31-101, or local policy.

The date the background check was completed, the credential issue date, and the credential expiration date will entered.

The VCC Issuing Official will sign and date indicating issuance of a DBIDS credential.

If the Applicant has a completed AW Form 2 designating escort privileges, the box will be checked and the escort limit filled in.

AW FORM 1, 20160926