4-BASE ACCESS REQUEST (2024)(1).pdf
PDF 300 KB Posted
- Solicitation number
- RFP 171 260000002440 4
- Issued by
- Calhoun County, Michigan
About this file
This is a Base Access Request Form (SF Form 90) issued by the 110th Security Forces Squadron located at Battle Creek Air Force Base in Michigan. The form serves as an application for contractors and vendors to obtain access to the secure military installation. Applicants must complete personal information including citizenship status, name, date of birth, racial and ethnic categories, current address, and phone number. Contractors or vendors must provide company information, a general contractor designation if applicable, company contact numbers, and job site details. A sponsor from the military installation must also complete their section, including sponsor name, unit, contact information, and signature authorization. Access expiration dates must be specified, and the frequency of visits to the installation must be documented as daily (Monday-Friday), weekly (1-2 times per week), or monthly (1-2 times per month).
The form requires applicants to consent to criminal history checks and LEIN (Law Enforcement Information Network) checks as a mandatory requirement for installation access. All information collected is maintained under the Privacy Act of 1974 and is for official use only. The form must be completed and emailed to 110.MSG.Pass.-.ID.Org@us.af.mil. Failure to provide complete and accurate information may result in denial of base access. The principal authority for this requirement is derived from Title 10 United States Code, Sections 504, 505, 508, and 12102, and Executive Order 9397. Information provided may be disclosed to law enforcement agencies for criminal investigations or to the Department of Justice for purposes of representation.
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Text version
SF FORM 90, 26 June 2024 PREVIOUS EDITION IS OBSOLETE. MS Excel 2007
11a.
DAILY (Mon-Fri)
WEEKLY (1-2 times per week)
MONTHLY (1-2 imtes per month)
12h. LEIN COMPLETED DATE (YYYYMMDD) 14. DEROGATORY FINDINGS
NO YES
12e. Agency: 110th Security Forces Squadron 12f. Agency Address: 34 Sabre Street, Battle Creek, MI 49035 12g. ORI#: MIAF00400
12. PERSON COMPLETING THIS REQUEST
12a. NAME (Last, First, Middle Name(s)) 12b. RANK 12c. SIGNATURE 12d. TITLE
12. SCAN DRIVERS LICENSE IN THIS SPACE.
SECTION V - (To be completed by Security Forces Pass and ID member completing records check) The person described above has applied for access to a secure military installation therefore a LEIN check is required for installation access to be granted.
9a. COMPANY NAME 10a. SPONSOR NAME
9b. GENERAL CONTRACTOR 10b. SPONSOR UNIT
9c. COMPANY CONTACT NUMBER 10c. SPONSOR CONTACT NUMBER
9d. JOB SITE 10d. SPONSOR SIGNATURE
9e. START DATE 11b. ACCESS EXPIRATION DATE
8. I HEREBY CONSENT TO A CRIMINAL HISTORY CHECK AS REQUIRED TO GAIN
ACCESS TO A MILITARY INSTALLATION.
APPLICANT'S SIGNATURE
SECTION II - (Contractor/Vendor Info) SECTION III - (Sponsor Info) SECTION IV - (Frequency of Visits)
7. CURRENT ADDRESS AND PHONE NUMBER
7a. NUMBER AND STREET (Include Apartment No.) 7b. CITY 7c. STATE 7d. ZIP CODE 7e. PHONE NUMBER
The data are for OFFICIAL USE ONLY and will be maintained and used in strict confidence in accordance with Federal law and regulations. Making a knowing and willful false statement on this Form may be punishable by fine or imprisonment or both. All information provided by you, which possibly may reflect adversely on your past conduct and performance, may have an adverse impact on your clearance for base access.
SECTION I - (Applicant's Personal Information)
2. NAME OF APPLICANT (Last, First, Middle(s), Alias)
3. SEX 4. DATE OF BIRTH (YYYYMMDD) 5. RACIAL CATEGORY (X one or more) 6. ETHNIC CATEGORY
MALE
FEMALE
(1) AMERICAN INDIAN / ALASKA NATIVE (2) ASIAN (3) WHITE (1) HISPANIC / LATINO
(2) NOT HISPANIC / LATINO
(4) BLACK / AFRICAN AMERICAN (5) NATIVE HAWAIIAN / OTHER PACIFIC ISLANDER
1. CITIZENSHIP: U.S. Citizen Foreign National If FN, which country?
BASE ACCESS REQUEST 1. DATE OF REQUEST (YYYYMMDD)
PLEASE EMAIL COMPLETED FORM TO: 110.MSG.Pass.-.ID.Org@us.af.mil This form requires collection and maintaining information protected by the Privacy Act of 1974. System of records Notice F031 AF SP O applies.
AUTHORITY: Title 10 United States Code, Sections 504, 505, 508, and 12102; E.O. 9397.
PRINCIPAL PURPOSE: To determine eligibility of a prospective contractor to be allowed access into an Armed Forces of the United States installation.
ROUTINE USES: Information collected on this form may be released to law enforcement agencies engaged in the investigation or prosecution of a criminal act or the enforcement or implementation of a statute, rule, regulation or order; to any component of the Department of Justice for the purpose of representing the DoD. DISCLOSURE: Voluntary; however, failure of the applicant to complete this form may result in refusal of access into an Armed Forces of the United States installation.
mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil mailto:110.MSG.Pass.-.ID.Org@us.af.mil
Table 1
| 1 DATE OF REQUEST YYYYMMDDBASE ACCESS REQUEST: |
| SECTION I Applicant s Personal Information: |
| 1 CITIZENSHIP US Citizen Foreign National If FN which country: |
| 2 NAME OF APPLICANT Last First Middles Alias: |
| 7a NUMBER AND STREET Include Apartment No: |
| 7b CITY: |
| 7c STATE: |
| 7d ZIP CODE: |
| 7e PHONE NUMBER: |
| APPLICANTS SIGNATURE: |
| SECTION II ContractorVendor Info: |
| SECTION III Sponsor Info: |
| SECTION IV Frequency of Visits: |
| 9a COMPANY NAME: |
| 10a SPONSOR NAME: |
| 9b GENERAL CONTRACTOR: |
| 10b SPONSOR UNIT: |
| 9c COMPANY CONTACT NUMBER: |
| 10c SPONSOR CONTACT NUMBER: |
| 9d JOB SITE: |
| 9e START DATE: |
| 10d SPONSOR SIGNATURE: |
| 11b ACCESS EXPIRATION DATE: |
| 12 PERSON COMPLETING THIS REQUEST: |
| 12a NAME Last First Middle NamesRow1: |
| 12b RANKRow1: |
| 12c SIGNATURERow1: |
| 12d TITLERow1: |
| 12h LEIN COMPLETED DATE YYYYMMDDRow1: |
| Check Box1: Off |
| Check Box2: Off |
| Check Box3: Off |
| Check Box4: Off |
| Check Box5: Off |
| Check Box6: Off |
| Check Box7: Off |
| DATE OF BIRTH: |
| Check Box9: Off |
| Check Box10: Off |
| Check Box11: Off |
| Check Box12: Off |
| Check Box13: Off |
| Check Box14: Off |
| Check Box15: Off |
| Check Box16: Off |
| Check Box17: Off |
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