117th Site Visit Request.pdf
PDF 129 KB Posted
- Attached to
- 117th ARW Alert Pad Crack Repairs
- Solicitation number
- W50S6M26QA013
About this file
This is a badge/visitor access request form for the 117th Air Refueling Wing (117 ARW).
The form collects personal identification information from individuals requesting access to 117 ARW property, including name, date of birth, Social Security number, driver's license number, home address, citizenship status, physical descriptors, and contact information. Applicants must indicate whether they are requesting long-term access (31 days or more) or short-term access (30 days or less) and select their visitor type: Government Employee, Government Contractor, Visitor, Volunteer, Student, or Caretaker. The form requires specification of access dates, times, and days of the week requested, along with sponsor/requestor agency information and business purpose. Applicants must acknowledge understanding of installation driving procedures. The collection of this information is authorized under Executive Order 9379, the Privacy Act of 1974, DoD Directive 8500.1, and associated security standards (HSPD-12, DoD 5200.8, DTM 09-12, FIPS 201, and AFI 31-113). The disclosure of requested information is voluntary but failure to provide it may result in denial of access credentials. The form includes a section for 117 Security Forces use only for background checks conducted through NCIC/LETS systems.
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| File | Type | Posted |
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| IMG_0131.jpeg | JPEG file | |
| IMG_0130.jpeg | JPEG file | |
| IMG_0132.jpeg | JPEG file | |
| Wage Determination.pdf | ||
| SOW_Crack seal and expansion joint .docx | DOCX document | |
| Solicitation - W50S6M26QA013_Final.pdf |
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Text version
117 SFS BADGE/ VISITOR REQUEST
(Subject to the Privacy Act of 1974)
PRIVACY ACT STATEMENT
AUTHORITY: E.O. 9379; The Privacy Act of 1974, 5 U.S.C. 522a; DODD 8500.1
PRINCIPAL PURPOSE(S): To provide necessary information to determine if applicant meets installation access control requirements IAW HSPD12, DoD 5200.8, DTM 09-12, FIPS201, AND AFI 31-113. Use of SSN is necessary to make positive identification of an applicant. Records in the Defense Biometric Identification System (DBIDS) are maintained to support DoD physical security and information assurance programs and are used for identity verification purposes, to record personal property registered with the DoD, and for producing facility management reports. SSN, Drivers License Number, or other acceptable identification will be used to distinguish individuals who request access to 117 ARW property.
DISCLOSURE: Voluntary. However, failure to provide the requested information may result in denial of an access credential and denial of access to 117 ARW property.
REQUIRES ACCES TO
117 ARW
LONG TERM (31 days or more)
SHORT TERM (30 days or less)
TYPE:
GOV Employee
GOV Contractor
Visitor
Volunteer
Student
Caretaker
I. VISITOR’S INFORMATION
NAME (Last, First Middle)
BIRTH (MM/ DD/ YYYY)
SOCIAL SECURITY NUMBER
ETHNICITY
DRIVER’S LICENSE NUMBER
STATE
COMPANY/ UNIT
HOME ADDRESS
TELEPHONE NUMBER EMAIL ADDRESS
US CITIZEN? ALIEN/ PASSPORT NUMBER/ COUNTRY OF
BIRTH (Non-US Citizen)
GENDER HEIGHT (ft/in) WEIGHT (lbs) EYE COLOR HAIR COLOR
YES
NO
Does Applicant have a valid Federally Issued Common Access Card (CAC) or TWIC? YES □ NO □
II. ORGANIZATION/ SPONSOR AND ACCESS DATES/TIMES
START DATE (MM/DD/YYYY)
DAY/ TIME REQUESTING ACCESS
Hours (e.g.
0700- 1700)
MON TUES WED THUR FRI SAT SUN
END DATE (MM/DD/YYYY)
REQUESTOR/SPONSOR
AGENCY/ORGANIZATION
BUSINESS/DUTY PHONE
SIGNATURE
DATE
REMARKS
III. ACKNOWLEDGEMENT OF INSTALLATION DRIVING PROCEDURES: INITIALS
IV. 117 SFS USE ONLY
ON SRBW DATE OF NCIC/ LETS
CHECK
NCIC OPERATOR COMMENTS
YES
NO
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| NAME Last First Middle: |
| BIRTH MM DD YYYY: |
| SOCIAL SECURITY NUMBER: |
| ETHNICITY: |
| DRIVERS LICENSE NUMBER: |
| STATE: |
| COMPANY UNIT: |
| HOME ADDRESS: |
| TELEPHONE NUMBER: |
| EMAIL ADDRESS: |
| GENDERALIEN PASSPORT NUMBER COUNTRY OF BIRTH NonUS Citizen: |
| START DATE MMDDYYYY: |
| END DATE MMDDYYYY: |
| MONHours eg 0700 1700: |
| TUESHours eg 0700 1700: |
| WEDHours eg 0700 1700: |
| THURHours eg 0700 1700: |
| FRIHours eg 0700 1700: |
| SATHours eg 0700 1700: |
| SUNHours eg 0700 1700: |
| REQUESTORSPONSOR: |
| AGENCYORGANIZATION: |
| BUSINESSDUTY PHONE: |
| REMARKS: |
| INITIALS: |
| DATE OF NCIC LETS CHECK: |
| NCIC OPERATOR: |
| COMMENTS: |
| Check Box26: Off |
| Check Box27: Yes |
| Check Box28: Off |
| Check Box29: Off |
| Check Box30: Yes |
| Check Box31: Off |
| Check Box32: Off |
| Check Box33: Off |
| Check Box34: Off |
| Check Box35: Off |
| Check Box36: Off |
| Check Box37: Yes |
| Check Box38: Off |
| Check Box39: Off |
| HEIGHT ft/in: |
| WEIGHT lbs: |
| EYE COLOR: |
| HAIR COLOR: |
| Text2: |
File details come from the government source that posted it. Updated .