Clearance_Information_and_Request_Form.pdf

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Replacement of 8 HVAC Systems at the United States Bullion Depository (Ft. Knox, Kentucky)
Solicitation number
2031JG19P00084
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Clearance Information and Request Form

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Q&A.pdf PDF
RFQ_2031JG19P00084,_“Replacement_of_8_HVAC_Systems_at_the_United_States_Bullion_Depository”.pdf PDF

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UNITED STATES MINT POLICE

Clearance Information and Request Form

PLEASE PRINT CLEARLY

U.S. Citizen YES _______ NO _______ Passport No. (If Applicable) _______________

LAST NAME: ___________________________ FIRST ____________________ MI __________

Sex _________ Race ______________________ Date of Birth _____________________________

Place of Birth ______________________________________________________________________

SSN: ______________________________

Residence Address

Street Number: ___________________ Street Name: __________________________________

Town/City: ____________________ State: ______________ Zip Code: _____________

Contractor/Company Name AND Cage Code:________________________________________

Street Number: ___________________ Street Name: __________________________________

Town/City: ____________________ State: ______________ Zip Code: ________________

Telephone / Fax ____________________________________________________________________

Identification Information

Driver License Number: _____________ State Issued By: ________ Expiration Date: ________

Arrival Date: __________________ Estimated Arrival Time: ______________________________

Purpose of Visit ____________________________________________________________________

Name of Employee Requesting Clearance ______________________________________________

To Return Form by Fax: 502-942-2153 To Return Form by Email: Thomas.Trigg@usmint.treas.gov (Form must be protected/encrypted)

NCIC REFERENCE NUMBER: ________________ FBI REFERENCE NUMBER: _________________

mailto:xxxxxx@usmint.treas.gov

U.S. Citizen YES _______ NO _______ Passport No. (If Applicable) _______________

YES:
NO:
Passport No If Applicable:
LAST NAME:
FIRST:
MI:
Sex:
Race:
Date of Birth:
Place of Birth:
SSN:
Street Number:
Street Name:
TownCity:
State:
Zip Code:
Contractor Company Name:
Street Number_2:
Street Name_2:
TownCity_2:
State_2:
Zip Code_2:
Telephone Fax:
Driver License Number:
State Issued By:
Expiration Date:
Arrival Date:
Estimated Arrival Time:
Purpose of Visit:
Name of Employee Requesting Clearance:
NCIC REFERENCE NUMBER:
FBI REFERENCE NUMBER:

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