6. SIOAN Form 380-2 Personnel Data Questionnaire.pdf
PDF 148 KB Posted
- Solicitation number
- W911KF-22-Q-0022
About this file
This document is a personnel data questionnaire form required for individuals requesting unescorted access to Anniston Army Depot. The form collects personal identification information such as name, date of birth, physical description, citizenship status, addresses for the past five years, and certification by an authorized personnel representative. It will be used to conduct screening and issue photo or non-photo badges granting base access. Non-photo badges may include restrictions such as requiring an escort. Approval or denial of access lies with the base security officials reviewing this completed form.
The related federal contract opportunity is a solicitation from the Department of the Army Materiel Command Contracting Command Detroit Arsenal to upgrade one M1 Full Up Power Pack Ground Hop stand located at Anniston Army Depot. The contractor will be responsible for designing and fabricating all required equipment, which includes providing and installing a host computer, data acquisition system, UPS, software updates, holding tanks with filtration systems for turbine engine oil and transmission oil, performance testing, training depot personnel, and defining emergency warranty maintenance in a statement of work.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Request Recurring: Yes / No PERSONAL DATA QUESTIONNAIRE – (See AR 380-67 for use of this form; proponent is AMSTA-AN-ESP)
CONTRACTOR COMPANY NAME (Prime)
WORK PHONE
SUBCONTRACTOR NAME
CONTRACT NUMBER
CONTRACT EXPIRES
INDIVIDUAL’S NAME (First name, Middle name, Last name) ***NO INITIALS ***
SSN
OTHER NAMES USED (INCLUDE FORMER MARRIED NAMES)
TYPE BADGE/AREA:
DATE OF BIRTH PLACE OF BIRTH CITIZENSHIP
MONTH
DAY
YEAR
CITY
COUNTY
STATE
*** NOTE ***IF YOU WERE BORN OUTSIDE OF THE UNITED STATES, YOU MUST FURNISH PROOF OF U.S.
CITIZENSHIP UPON SUBMISSION OF THIS FORM TO THIS INSTALLATION. PROOF OF U.S. CITIZENSHIP MUST BE SUBMITTED IN PERSON BY THE INDIVIDUAL, ALONG WITH THIS FORM, TO THE BADGE OFFICE, PHYSICAL SECURITY DIVISION, DES.
PHYSICAL DESCRIPTION COLOR EYES
COLOR HAIR
HEIGHT
WEIGHT
SEX
RACE
DRIVERS LICENSE NO.
STATE OF ISSUE
OR STATE IDENTIFICATION NO.
STATE OF ISSUE
ADDRESSES FOR THE PAST FIVE (5) YEARS, INCLUDING PRESENT ADDRESS: (STREET, CITY, COUNTY, STATE)
1. 4.
(County) (County)
2. 5.
(County) (County)
3. 6.
(County) (County) AUTHORITY: Internal Security Act of 1950 (50 USC 797); Executive Order 9397. PRINCIPAL PURPOSE: To document information necessary for selection, assignment or termination for persons desiring entry to all, or parts, of Anniston Army Depot.
ROUTINE USES: The information provided will be furnished to the Directorate of Emergency Services at Anniston Army Depot; to officials within the Department of Defense who have a need for it to perform official business. NATURE OF DISCLOSURE:
Disclosure of the requested information is voluntary. Failure to provide the information, however, may result in being denied unescorted access to the installation.
LEGAL SIGNATURE OF INDIVIDUAL REQUESTING ACCESS:
DATE
********************** CERTIFICATION **********************
I certify that the individual named above is, in fact, an employee of the company as listed above. I understand that a knowing and willful false statement can be punished by fine or imprisonment, or both. (U.S. Code, title 18 USC 1001)
SIGNATURE OF AUTHORIZED PERSONNEL/REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
DISAPPROVED SIGNATURE OF DISAPPROVING OFFICIAL
APPROVED
____ PHOTOGRAPHIC BADGE
____ NON-PHOTOGRAPHIC BADGE – NO ESCORT REQUIRED
____ NON-PHOTOGRAPHIC BADGE - ESCORT REQUIRED
NO DRIVING PRIVILEGES
Badge Office Issues Letter
SIGNATURE OF APPROVING OFFICIAL: DATE
SIOAN Form 380-2, Rev 11 Mar 08 PREVIOUS EDITIONS OBSOLETE
| SSN |
| TYPE BADGE/AREA: |
| CITIZENSHIP |
| PLACE OF BIRTH |
| DATE OF BIRTH |
| STATE |
| COUNTY |
| CITY |
| YEAR |
| DAY |
| MONTH |
| *** NOTE ***IF YOU WERE BORN OUTSIDE OF THE UNITED STATES, YOU MUST FURNISH PROOF OF U.S. CITIZENSHIP UPON SUBMISSION OF THIS FORM TO THIS INSTALLATION. PROOF OF U.S. CITIZENSHIP MUST BE SUBMITTED IN PERSON BY THE INDIVIDUAL, ALONG WITH THIS FORM, TO THE BADGE OFFICE, PHYSICAL SECURITY DIVISION, DES. |
| HEIGHT |
| WEIGHT |
| SEX |
| RACE |
| PHYSICAL DESCRIPTION |
| COLOR EYES |
| COLOR HAIR |
| STATE OF ISSUE |
| STATE IDENTIFICATION NO. |
| OR |
| STATE OF ISSUE |
| DRIVERS LICENSE NO. |
| ADDRESSES FOR THE PAST FIVE (5) YEARS, INCLUDING PRESENT ADDRESS: (STREET, CITY, COUNTY, STATE) |
| 4. |
| 1. |
| (County) |
| 5. |
| (County) |
| 6. |
| (County) |
| AUTHORITY: Internal Security Act of 1950 (50 USC 797); Executive Order 9397. PRINCIPAL PURPOSE: To document information necessary for selection, assignment or termination for persons desiring entry to all, or parts, of Anniston Army Depot. ROUTINE USES: The information provided will be furnished to the Directorate of Emergency Services at Anniston Army Depot; to officials within the Department of Defense who have a need for it to perform official business. NATURE OF DISCLOSURE: Disclosure of the requested information is voluntary. Failure to provide the information, however, may result in being denied unescorted access to the installation. |
| DATE |
| LEGAL SIGNATURE OF INDIVIDUAL REQUESTING ACCESS: |
| ********************** CERTIFICATION ********************** |
| DATE |
| SIGNATURE OF AUTHORIZED PERSONNEL/REPRESENTATIVE |
| DO NOT WRITE BELOW THIS LINE |
| DATE |
| SIGNATURE OF DISAPPROVING OFFICIAL |
| DISAPPROVED |
| NO DRIVING PRIVILEGES |
| APPROVED |
| DATE |
| SIGNATURE OF APPROVING OFFICIAL: |
File details come from the government source that posted it. Updated .