9. Contractor Request Form - AST UST Site Visit (002).pdf

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JBMDL - Above and Underground Tank Maintenance and Repair
Solicitation number
FA448426R0016
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This is a Contractor Request Form used by the 87th Air Base Wing (AMC) at Joint Base McGuire-Lakehurst-Dix to process access requests for contractor personnel and visitors to the military installation.

The form requires the requesting sponsor to provide information about the individual(s) seeking access, including full name, company affiliation, date of birth, full Social Security number, required access dates (start and end), days and times of access needed, and whether sponsorship privileges are necessary. The sponsor must identify their building location and contact information, specify the visitor's destination or purpose for card/pass rights, and provide their signature along with DOD ID number, rank, service, title, and organization. The form indicates that not all personnel will be granted permissions and that NCOIC or Welcome Center Supervisors can deny access if applicants do not meet proper criteria. Information collected is maintained in a central Security Forces database and may be disclosed to public affairs and security representatives for official duties. The sponsor must initial an acknowledgment of four key responsibilities: advising guests of base entry procedures and limitations including health precautions and facility use restrictions; accepting accountability for guest conduct and actions; serving as the point of contact for police actions involving guests; and acknowledging that individuals with disqualifying criminal history or prior military installation bans will be denied entry.

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DEPARTMENT OF THE AIR FORCE

87TH AIR BASE WING (AMC)

JOINT BASE MCGUIRE-LAKEHURST-DIX

MEMORANDUM FOR 87 SFS/WELCOME CENTER

FROM:

SUBJECT: Contractor Request Form

1. Request entry for the following individual(s) allowing access onto Joint Base MDL for the purpose of

If sponsorship privileges are needed type Yes or No: Not all personnel will be granted permissions. NCOIC or Welcome Center Supervisors can deny an individual if deemed they do not meet the proper criteria.

2. I work in building and can be reached at .

3. The visitor will be going to or state purpose for card/pass rights .

4. Dates Access required: Start Date End Date: .

NAME

(Last, First Middle

Initial)

COMPANY

NAME

FULL SSN Date of Birth Days of week access required

Time's access required

Sponsorship Privileges Yes or No

5. Please direct any questions regarding this matter to the member stated below.

Signature and DOD ID Number

First Mi Last, Rank, Service

Title, Organization

PRIVY ACT STATEMENT

AUTHORITY: 5 U.S.C. 301.10 U.S.C. 8012 and 8034, and EO 9397.

PRINCIPAL PURPOSE: To verify individual status and conduct any background checks to determine if access to Joint Base McGuire-Dix-Lakehurst(JB MDL) is warranted. ROUTINE USE: All information will be maintained in a central Security Forces database and may be disclosed to public affairs and security representatives to carry out official duties. Information will not be considered “Public Domain” and will be safeguarded by the end users.

DISCLOSURE: Information collected on this form and your signature are voluntary. If you have no objection to these procedures fill out the form and sign your name. Failure to provide the requested information or a signature may lead to denial of access and privileges at JB MDL.

example: 0900-2100

Contractor Signature

1187097149C Highlight

1187097149C Highlight

1187097149C Highlight

1187097149C Highlight

SPONSOR REQUIRED TO INITIAL BELOW ACKNOWLEDGING THEIR RESPONSIBILITIES

1. Sponsor will advise all guests of base entry procedures and limitations while on base to include required health precautions, speed limits, cell phone use, and use of base facilities.

2. Sponsor understands they are responsible for the conduct of all guests and will be held accountable for all actions of their guests.

3. Sponsor is the point of contact for any police actions concerning their guests.

4. Sponsor acknowledges that anyone named on the attached form that has disqualifying factors on a criminal check or has been barred from a military installation will be denied entry. The sponsor will be notified of the results of these checks.

SPONSORS INITIALS:

MEMORANDUM FOR 87 SFS/S5W
FROM:
FIRST MI LAST, RANK, SERV
1 Request entry for the following individual allowed access onto Joint Base MDL for the purpose of:
2 I work in building:
and can be reached at:
NAME Last First Middle InitialRow1:
COMPANY NAMERow1:
FULL SSNRow1:
Date of BirthRow1:
Days of week access requiredRow1:
Hours of day access requiredRow1:
Sponsorship Privileges Yes or NoRow1:
NAME Last First Middle InitialRow2:
COMPANY NAMERow2:
FULL SSNRow2:
Date of BirthRow2:
Days of week access requiredRow2:
Hours of day access requiredRow2:
Sponsorship Privileges Yes or NoRow2:
NAME Last First Middle InitialRow3:
COMPANY NAMERow3:
FULL SSNRow3:
Date of BirthRow3:
Days of week access requiredRow3:
Hours of day access requiredRow3:
Sponsorship Privileges Yes or NoRow3:
NAME Last First Middle InitialRow4:
COMPANY NAMERow4:
FULL SSNRow4:
Date of BirthRow4:
Days of week access requiredRow4:
Hours of day access requiredRow4:
Sponsorship Privileges Yes or NoRow4:
NAME Last First Middle InitialRow5:
COMPANY NAMERow5:
FULL SSNRow5:
Date of BirthRow5:
Days of week access requiredRow5:
Hours of day access requiredRow5:
Sponsorship Privileges Yes or NoRow5:
NAME Last First Middle InitialRow6:
COMPANY NAMERow6:
FULL SSNRow6:
Date of BirthRow6:
Days of week access requiredRow6:
Hours of day access requiredRow6:
Sponsorship Privileges Yes or NoRow6:
NAME Last First Middle InitialRow7:
COMPANY NAMERow7:
FULL SSNRow7:
Date of BirthRow7:
Days of week access requiredRow7:
Hours of day access requiredRow7:
Sponsorship Privileges Yes or NoRow7:
NAME Last First Middle InitialRow8:
COMPANY NAMERow8:
FULL SSNRow8:
Date of BirthRow8:
Days of week access requiredRow8:
Hours of day access requiredRow8:
Sponsorship Privileges Yes or NoRow8:
NAME Last First Middle InitialRow9:
COMPANY NAMERow9:
FULL SSNRow9:
Date of BirthRow9:
Days of week access requiredRow9:
Hours of day access requiredRow9:
Sponsorship Privileges Yes or NoRow9:
NAME Last First Middle InitialRow10:
COMPANY NAMERow10:
FULL SSNRow10:
Date of BirthRow10:
Days of week access requiredRow10:
Hours of day access requiredRow10:
Sponsorship Privileges Yes or NoRow10:
NAME Last First Middle InitialRow11:
COMPANY NAMERow11:
FULL SSNRow11:
Date of BirthRow11:
Days of week access requiredRow11:
Hours of day access requiredRow11:
Sponsorship Privileges Yes or NoRow11:
NAME Last First Middle InitialRow12:
COMPANY NAMERow12:
FULL SSNRow12:
Date of BirthRow12:
Days of week access requiredRow12:
Hours of day access requiredRow12:
Sponsorship Privileges Yes or NoRow12:
NAME Last First Middle InitialRow13:
COMPANY NAMERow13:
FULL SSNRow13:
Date of BirthRow13:
Days of week access requiredRow13:
Hours of day access requiredRow13:
Sponsorship Privileges Yes or NoRow13:
FIRST MI LAST RANK SERV:
Title Organization:
Text1:
Text2:
Start Date_af_date:
End Date_af_date:
initals:

File details come from the government source that posted it. Updated .