Atch 4 - SAFB 151 Base Pass.pdf

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APPLICATION FOR PERSONNEL PASS TO WORK UNDER AIR FORCE CONTRACT (See Privacy Act Statement and General Instructions below) 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 suitability for access to Sheppard AFB TX to work under Air Force Contracts.

ROUTINE USE: All contractors, subcontractors, units of Sheppard AFB sponsoring activities who have employees not authorized a Common Access Card and requiring regular and frequent access to Sheppard AFB in performance of their official duties.

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information is voluntary; however, failure to provide information will result in access privileges being refused or withdrawn.

SECTION I: Contractor must ensure all blocks are complete.

PLACE OF BIRTH

NOTE TO APPLICANT:

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 fingerprintes, 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 include 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 the application can be punished by fine, imprisonment, or both (18 U.S.C. Section 1001)

SECTION II: To be completed by the employees Contractor Program Manager/Supervisor THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JUSRISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED SATES CODE, SECTION 1001 OR OTHER APPLICABLE LAWS AND REGULATIONS. NOTE: "CONTRACTOR AND EMPLOYEE" SHALL RETURN BADGE TO THE 82D SECURITY FORCES PASS & ID UPON EXPIRATION OR TERMINATION OF THE 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, you will collect the ID or report the card stolen to 82d Security Forces Pass and ID (940-676-0336).

SHEPPARDAFB151, 20190228 PRESCRIBING DIRECTIVE: AFMAN31-113_SHEPPARDAFBSUP

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 or 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.

SECTION IV: To be completed by 82d Security Forces Pass & ID

82D SECURITY FORCES PASS & ID USE ONLY

Approve/Disapprove Reason:

SHEPPARDAFB151, 20190228 PRESCRIBING DIRECTIVE: AFMAN31-113_SHEPPARDAFBSUP

11.0.1.20130826.2.901444.899636