Atch 05 Grounds MX - SAFB 151 Base Pass.pdf

APPLICATION FOR PERSONNEL PASS TO WORK UNDER AIR FORCE CONTRACT

(See Privacy Act Statement and General Instructions below

PRIVACY ACT STATEMENT

SECTION I: Contractor must ensure all blocks are complete.

1.1 THRU (CONTRACTING OFFICE SPONSORING ACTIVITY ADDRESS) 1.2 FROM (PRIME CONTRACTOR’S NAME, ADDRESS, PHONE)

1.3 CONTRACT NUMBER 1.4 REQUESTED EXPIRATION DATE FOR ID 1.5 DAYS/HOURS WORKED 1.6 LOCATION OF WORK BEING CONDUCTED

1.7 NAME (LAST, FIRST, MIDDLE) 1.8 SOCIAL SECURITY # 1.9 DATE OF BIRTH 1.10 DRIVER LICENSE #/STATE

1.11 SEX 1.12 RACE 1.13 HAIR COLOR 1.14 EYE COLOR 1.15 HEIGHT (FT/IN)

1.16 WEIGHT

1.17 ALIAS 1.18 SCARS/MARKS/TATTOOS

PLACE OF BIRTH

1.19 CITY 1.20 STATE 1.21 COUNTRY

1.22 CITIZENSHIP 1.23 RESIDENT ALIEN # OR IMMIGRATION DOCUMENT # AND DESCRIPTION

NOTE TO APPLICANT: ATTESTATION

I attest to the fact that I have been briefed by my employer and understand the purpose for the contractor background check. I understand the information on this form is being collected in accordance with 50 U.S.C., Section 797, DoDD 5200.8, and AFI 31-113 federal laws permitting the installation commander to limit access to the installation for security reasons and that this data will be used to screen DoD contractor’s employees who have or are seeking access to US Air Force installations. I have voluntarily completed this "Form" and shall provide the Air Force a specimen of my fingerprints, if/when requested. I understand that by signing this application, I acknowledge that I have been made aware of and have reviewed the list of Sheppard AFB "Disqualifying Factors" provided by the contracting officer. I hereby give my consent and authorization for the Air Force to conduct any additional background screenings deemed necessary over the next 24 months, unless otherwise directed by 82 CONS, to included comparing/checking my fingerprints against local state, and federal criminal databases. The information I have provided on this application is true, complete, and correct to the best of my knowledge and belief, and is provided in good faith. I understand that a knowing and willfully false statement on this application can be punished by fine or imprisonment or both (18 U.S.C Section 1001).

1.24 Applicant Printed Name

1.25 Date:

1.26 Applicant Signature :

SECTION II: To be completed by the employees Contractor Program Manager/Supervisor THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED STATES CODE, SECTION 1001 OR OTHER APPLICABLE

LAWS AND REGULATIONS.

NOTE: “CONTRACTOR AND EMPLOYEE” SHALL RETURN BADGE TO SF PASS & ID UPON EXPIRATION OR TERMINATION OF CONTRACT

Your signature is a confirmation that the personnel listed in Section I is working under your contract and does require an access badge for Sheppard Air Force Base.

You are also confirming that if the personnel in Section I is terminated or quits before the expiration on the base access badge, that you will collect ID or report card stolen to 82SFS Pass & ID 940-676-0336.

2.1 Contractor program manager/supervisor printed name:

2.2 Contractor program manager/supervisor signature: 2.3 Date:

SECTION III: To be completed by Contracting Office/Sponsoring Agency THIS IS TO CERTIFY: I have verified that the individual above is performing in an official capacity on referenced contract and/or requires a badge in the performance of their official duties on Sheppard AFB in accordance with the contract terms and conditions.

3.1 Contracting Officer/Sponsoring Agency Name & Phone Number:

3.2 Signature: 3.3 Date:

SAFB Form 151, 24 Apr 14

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AUTHORITY: 10 U.S.C. 8013, Executive Order 9397, as amended by 13478 PURPOSE: The purpose of requesting personal information is to assist security personnel in developing records to document contractor employee

ROUTINE USE: All contractors , subcontractors, units of Sheppard AFB sponsoring activities who have employees not authorized a Common Access Card

DISCLOSURE: Disclosure of requested information is voluntary; however, failure to provide information will result in access privileges being refused or

SAFB Form 151

SECTION IV: To be completed by Security Forces Pass & ID

THIS IS TO CERTIFY: I have verified the person listed in Section I was ran in TCIC/NCIC and meets the Qualifying Factors If personnel listed in Section I are denied issuing official will writ e a brief synopsis of why personnel was denied.

4.1 DATE ISSUED 4.2 DATE EXPIRED 4.3 SIGNATURE OF ISSUING OFFICAL

PASS & ID USE ONLY

Approve/Disapprove Reason:

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