167 Background Check Form - Replace Ground Fuel Tanks.doc

APPLICATION FOR PERSONNEL AND VISITOR PASSES TO WORK OR VISIT UNDER

AIR FORCE/AIR NATIONAL GUARD

(INSTRUCTIONS)

1. All information must be completed; Print and Spell out First, Middle, and Last Names (no initials)

2. EMPLOYEE or VISITOR MUST ATTACH a legible copy of their Driver’s license or State I.D. Vehicle operators will need a valid copy of vehicle registration and certificate of automobile insurance.

SECTION I: Contractor or Visitor MUST ensure all blocks are filled that applies

TO: 167 SFS/SFA

Employee or Visitor Information

1.3.

NAME: (LAST, FIRST, MIDDLE)

1.4.

SOCIAL SECURITY #

1.5.

DATE OF BIRTH

1.6

SEX:

RACE:

Vehicle Information

(VEHICLES USED TO AND FROM WORK SITES or VISITING BASE)

1.7.

DRIVER LICENSE # & STATE OF DL

1.8.

MAKE/MODEL/YEAR

1.9

PLATE NO / STATE

THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED STATES CODE, SECTION 1001 OR OTHER APPLICABLE LAWS AND REGULATIONS.

NOTE: “CONTRACTOR OR VISITOR” SHALL RETURN BADGE TO SF PASS & ID UPON EXPIRATION OR TERMINATION OF CONTRACT OR AFTER THE VISIT.

1.10. EMPLOYEE OR VISTORS SIGNATURE: _______________________________________ DATE: ___________

1.11. PRIME CONTRACTOR’S CERTIFICATION: Employer certifies that employee is working on the above contract.

PRIME CONTRACTOR’S SIGNATURE: ____________________________________________________ DATE: ____________

1.12. If Employee is a sub-contractor employee: Complete below Sub-Contractor Company Name 1.13. 1. ____________________________________________________________________________

1.14. 2. Sub-Contractor’s Address and Phone Number: __________________________________________________________________

SECTION II: To be completed by Contracting Office/Sponsoring Activity (Section I BLOCK 1.2 THRU block)

2.1.

Contract Number W50S8V-22-B-0004 2.2.

Contract Expiration Date:

26 April 2022 2.3.

Days/Hours worked 2.4.

Place of Duty/ Building B119

THIS IS TO CERTIFY I have verified that the individual above is performing in an official capacity on referenced contract and/or requires a badge in the performance of their official duties on 167th Airlift Wing in accordance with the contract terms and conditions.

2.5. NAME OF CONTRACTING OFFICER/CONTRACT SPECIALIST/SPONSOR: RYAN E. BELFIELD

2.6. SIGNATURE: Ryan E. Belfield DATE: 7 April 2022

SECTION III: To be completed by Security Forces Pass and ID

3.1.

NCIC Check conducted on: ________________

3.2.

Badge Issue

Contractor: Yes__ No___

Vendor: Yes__ No__

Other: Yes__ No__ 3.3.

Date Issued

3.4.

Date Expires

PRIVACY ACT STATEMENT

AUTHORITY: Section 3101, Title 44, United States Code, AFI 33-332, 5 USC 552A

PRINCIPAL PURPOSE(S): The purpose for requesting personal information is to assist security personnel in developing records to document contractor employee suitability for access to the 167th Airlift Wing, Martinsburg, West Virginia, to work under Air Force contracts. The Social Security Number (SSN) and Date of Birth (DOB) are necessary to identify the person and records. This information may be used to determine suitability of persons desiring access to the 167th Airlift Wing as well as for other lawful purposes including law enforcement and litigation. INTENDED USE: All contractors, subcontractors, unit’s or 167th Airlift Wing sponsoring activities who have employees not authorized a Common Access Card and require regular and frequent access to 167th Airlift Wing in performance of their official duties. DISCLOSURE: Disclosure of requested information is mandatory. Failure to provide information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the Air Force contract while serving in the capacity of prime contractor or subcontractor/supplier employee.

167 SFS FORM BGC - 001 20141106