55 SFS NCIC Screening Pass Request-FILLED.pdf

PDF 360 KB Posted Jul 25, 2025

Attached to: B1000 Carpet Replacement
Solicitation number: FA460025Q0066
Issued by: Department of the Air Force Air Combat Command

About this file

Written by GovTribe AI · Jul 25, 2025

The document is a 55 SFS Contractor/Vendor NCIC Screening & Pass Request Spreadsheet for accessing Offutt Air Force Base, specifically related to the B1000 Carpet Replacement solicitation (FA460025Q0066). The form is designed to collect personally identifying information for contractors requiring base entry, including full name, date of birth, driver's license details, work schedule, and citizenship status. Contractors must submit this form by 05 August 2025 at 10:00 AM CST to SSgt Jose Buenaventura to gain installation access for the carpet replacement project.

The carpet replacement project involves approximately 2,350 square yards of carpet work on the Lower Level 1, including purchasing new Shaw Sculpt Loop carpet in Clay color, removing and replacing corridor carpets, and reusing salvaged carpet tiles in office spaces. The project requires purchasing approximately 1,450 sq yards of new carpet, replacing 1,100 sq yards of corridor carpet, and 350 sq yards of corridor carpet in a secure area. The solicitation includes a site visit scheduled for 07 August 2025 at 09:00 AM CST, with offers due on 25 August 2025 at 10:00 AM CST. Contractor communication should be directed to SSgt Jose Buenaventura and Mr. Casey L Hupton from the Department of the Air Force Air Combat Command.

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Full Name U.S. Citizen Last, First, MI Year Month Day Drivers License/ID # State SSAN Days Hrs Dates (MMDDYYY) Yes / No

Personally Identifying Information (PII) being collected by this form is authorized for collection under provisions of 10 U.S.C. 8013, Secretary of the Air Force, DoD 5200.2R, DoD Personnel Security Program; AFI 33-202, Computer Security, Information will be maintained by local

Security Forces Authority while access requirements exist. Information access is restricted to personnel responsible for contract administration, or otherwise needed in the performance of official DoD duties. Information will be properly disposed of when its required use has been concluded. Providing this information is voluntary; however, failure to provide all of the required data shown on the spreadsheet will result in denial of entry to the installation. This information is exempt from OMB licensing under provisions of AFI 33-324, Information Collections and

Reports Management Program; Controlling Internal, Public, and Interagency Air Force Collections, paragraphs 3.16.11 and 3.16.16.3.

55 SFS CONTRACTOR/VENDOR NCIC SCREENING & PASS REQUEST SPREADSHEET

Date of Birth

Offutt AFB Sponsoring Agency / Unit:

Base Sponsor's Name:

Base Sponsor's Phone #:

Request Date:

Work Schedule

Company Name:

Company Address:

Company Representative Name:

Company Representative Phone Number:

Contract#:

Contract Start/End Dates:

Sponsoring Unit Security Manager or Commander Signature Block/Signature

Offutt AFB Sponsoring Agency Unit:

Company Name:

Base Sponsors Name:

Company Address:

Base Sponsors Phone:

Company Representative Name:

Request Date:

Last First MIRow1:

YearRow1:

MonthRow1:

DayRow1:

Drivers LicenseID Row1:

StateRow1:

SSANRow1:

DaysRow1:

HrsRow1:

Dates MMDDYYYRow1:

Yes NoRow1:

Last First MIRow2:

YearRow2:

MonthRow2:

DayRow2:

Drivers LicenseID Row2:

StateRow2:

SSANRow2:

DaysRow2:

HrsRow2:

Dates MMDDYYYRow2:

Yes NoRow2:

Last First MIRow3:

YearRow3:

MonthRow3:

DayRow3:

Drivers LicenseID Row3:

StateRow3:

SSANRow3:

DaysRow3:

HrsRow3:

Dates MMDDYYYRow3:

Yes NoRow3:

Last First MIRow4:

YearRow4:

MonthRow4:

DayRow4:

Drivers LicenseID Row4:

StateRow4:

SSANRow4:

DaysRow4:

HrsRow4:

Dates MMDDYYYRow4:

Yes NoRow4:

Last First MIRow5:

YearRow5:

MonthRow5:

DayRow5:

Drivers LicenseID Row5:

StateRow5:

SSANRow5:

DaysRow5:

HrsRow5:

Dates MMDDYYYRow5:

Yes NoRow5:

Last First MIRow6:

YearRow6:

MonthRow6:

DayRow6:

Drivers LicenseID Row6:

StateRow6:

SSANRow6:

DaysRow6:

HrsRow6:

Dates MMDDYYYRow6:

Yes NoRow6:

Last First MIRow7:

YearRow7:

MonthRow7:

DayRow7:

Drivers LicenseID Row7:

StateRow7:

SSANRow7:

DaysRow7:

HrsRow7:

Dates MMDDYYYRow7:

Yes NoRow7:

Last First MIRow8:

YearRow8:

MonthRow8:

DayRow8:

Drivers LicenseID Row8:

StateRow8:

SSANRow8:

DaysRow8:

HrsRow8:

Dates MMDDYYYRow8:

Yes NoRow8:

Last First MIRow9:

YearRow9:

MonthRow9:

DayRow9:

Drivers LicenseID Row9:

StateRow9:

SSANRow9:

DaysRow9:

HrsRow9:

Dates MMDDYYYRow9:

Yes NoRow9:

Last First MIRow10:

YearRow10:

MonthRow10:

DayRow10:

Drivers LicenseID Row10:

StateRow10:

SSANRow10:

DaysRow10:

HrsRow10:

Dates MMDDYYYRow10:

Yes NoRow10:

Last First MIRow11:

YearRow11:

MonthRow11:

DayRow11:

Drivers LicenseID Row11:

StateRow11:

SSANRow11:

DaysRow11:

HrsRow11:

Dates MMDDYYYRow11:

Yes NoRow11:

Last First MIRow12:

YearRow12:

MonthRow12:

DayRow12:

Drivers LicenseID Row12:

StateRow12:

SSANRow12:

DaysRow12:

HrsRow12:

Dates MMDDYYYRow12:

Yes NoRow12:

Last First MIRow13:

YearRow13:

MonthRow13:

DayRow13:

Drivers LicenseID Row13:

StateRow13:

SSANRow13:

DaysRow13:

HrsRow13:

Dates MMDDYYYRow13:

Yes NoRow13:

Last First MIRow14:

YearRow14:

MonthRow14:

DayRow14:

Drivers LicenseID Row14:

StateRow14:

SSANRow14:

DaysRow14:

HrsRow14:

Dates MMDDYYYRow14:

Yes NoRow14:

Last First MIRow15:

YearRow15:

MonthRow15:

DayRow15:

Drivers LicenseID Row15:

StateRow15:

SSANRow15:

DaysRow15:

HrsRow15:

Dates MMDDYYYRow15:

Yes NoRow15:

Last First MIRow16:

YearRow16:

MonthRow16:

DayRow16:

Drivers LicenseID Row16:

StateRow16:

SSANRow16:

DaysRow16:

HrsRow16:

Dates MMDDYYYRow16:

Yes NoRow16:

Last First MIRow17:

YearRow17:

MonthRow17:

DayRow17:

Drivers LicenseID Row17:

StateRow17:

SSANRow17:

DaysRow17:

HrsRow17:

Dates MMDDYYYRow17:

Yes NoRow17:

Last First MIRow18:

YearRow18:

MonthRow18:

DayRow18:

Drivers LicenseID Row18:

StateRow18:

SSANRow18:

DaysRow18:

HrsRow18:

Dates MMDDYYYRow18:

Yes NoRow18:

Last First MIRow19:

YearRow19:

MonthRow19:

DayRow19:

Drivers LicenseID Row19:

StateRow19:

SSANRow19:

DaysRow19:

HrsRow19:

Dates MMDDYYYRow19:

Yes NoRow19:

Last First MIRow20:

YearRow20:

MonthRow20:

DayRow20:

Drivers LicenseID Row20:

StateRow20:

SSANRow20:

DaysRow20:

HrsRow20:

Dates MMDDYYYRow20:

Yes NoRow20:

Contract #:

Contract End Date:

Company Phone #:

File details come from the government source that posted it. Updated Jul 25, 2025.