Atch 11- Base Acess Template Example.pdf
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- Attached to
- Well 1 Pump Repair
- Solicitation number
- FA480325B0013
About this file
This document is a base access request template for the 20th Fighter Wing at Shaw Air Force Base in South Carolina. The form is designed to process criminal background history checks for contractors, employees, or other individuals seeking access to the base. Key details include:
The template requires sponsors to provide comprehensive information about the individual requesting base access, including full legal name, date of birth, social security number, driver's license details, and citizenship status. The form emphasizes the sponsor's responsibility for ensuring the individual turns in their Defense Biometric Identification System (DBIDS) pass when access is no longer required. The document is marked as Controlled Unclassified Information (CUI) and is protected under the Privacy Act of 1974, with clear warnings about potential consequences for misusing approved access privileges.
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Text version
DEPARTMENT OF THE AIR FORCE
20th FIGHTER WING (ACC)
SHAW AIR FORCE BASE SOUTH CAROLINA
CUI
Victory By Valor
DATE: XX/XX/XXXX
MEMORANDUM FOR 20 SFS/S-5V:
(email to: BOTH Ms. Jacqueline Hernandez-Sears jacqueline.hernandez-sears.1@us.af.mil, TSgt Shelby Pontieri shelby.pontieri@us.af.mil , OR FAX 803-895-5337……. DUTY #:803-895-9085 or 803-895-9086/ VCC Email: udg_20sfs_vcc@us.af.mil)
This form MUST be sent by the sponsor listed from their government email and received at the email addresses/fax number listed above in the 20 SFS/S-5V section.
FROM: (The person requesting background check be conducted and squadron/unit)
SUBJECT: (i.e Contractor/Employee needing access to Shaw AFB)
WHO: (Company or Organization the Contractor/Employee will be working for)
WHAT FOR: (i.e Construction, New Hire, Job Interview, Meeting, New CAC or CAC Renewal, Work order etc.)
WHERE: (Location Contractor/Employee will be working at or needing access to)
If base wide give justification: (i.e Individual needs access to multiple buildings on base)
WHEN: (The exact day/dates and hours the individual will need access to the base (i.e. May 10, 2022, 0800-1700hrs or from May 10, 2022- May 10, 2023 Monday-Saturday, 0700-1900hrs)
SPONSOR: (The CAC holding individual responsible for the individual listed below and their organization)
CONTACT INFO: (Sponsor’s GOV email and PHONE NUMBER W/EXTENSION)
The information below is protected under Privacy Act 1974 and will only be used to process Criminal Background History Checks to grant or deny access to Shaw AFB. It is further understood that anyone abusing approved privileges could, at a minimum, lose said privilege and possibly face criminal charges.
Full Legal Name (Last, First MI)
Date Of Birth (Year/Mo/Day)
Social Security Number
ST-DL #
(REAL ID Y/N)
U.S.
Citizen (Y/N)
********IF UNDER THE AGE OF 18, PLEASE COMPLETE A SEPARATE WORK REQUEST.*********
I UNDERSTAND THAT AS THE SPONSOR I AM RESPONSIBLE FOR THE PERSON(S) LISTED ON THIS FORM, AND FOR ENSURING THE ABOVE NAME INDIVIDUAL(S) TURNS IN THE DBIDS PASS OR RETRIEVE THE PASS ONCE THE INDIVIDUAL(S) ARE TERMINATED, QUIT, OR NO LONGER REQUIRES ACCESS. IF I AM NOT ABLE TO RETRIEVE THE PASS, I WILL NOTIFY SECURITY FORCES TO HAVE THE INDIVIDUAL(S) PASS DEACTIVATED IN DBIDS.
mailto:jacqueline.hernandez-sears.1@us.af.mil mailto:shelby.pontieri@us.af.mil
File details come from the government source that posted it. Updated .