Atch 8 - Base Access Request Form.pdf
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- Attached to
- Multi-Building Carpet & LVP
- Solicitation number
- FA480326Q0109
About this file
This is a Department of Air Force memorandum form used to request criminal background history checks and process base access for contractors and employees at Shaw Air Force Base in South Carolina.
The form is submitted by a government sponsor to the 20th Security Forces Squadron (20 SFS/S-5V) and must originate from the sponsor's government email address. Required submission recipients include Ms. Jacqueline Hernandez-Sears, SSgt Austin Simerly, and Mr. Joshua Arbeiter, with contact information provided via email and phone. The form captures essential information including the requestor's identity, the contracting organization, the purpose of base access (such as construction, new hire, job interview, CAC renewal, or work orders), the specific location on base where access is needed, and the exact dates and hours of required access. The sponsor must be a CAC-holding individual responsible for the visitor(s) and must provide their DOD EDPI number and government contact information. The form requires personal identifying information for each individual requiring access, including full legal name, date of birth, Social Security number, state driver's license number with Real ID status, and U.S. citizenship confirmation. The sponsor assumes responsibility for ensuring visitors return DBIDS passes upon termination or when access is no longer required, and must verify that all visitors possess Real ID-compliant identification or federal identification. Non-U.S. citizens must submit supporting documentation such as visas, permanent resident cards, or employment authorization cards prior to visiting the Visitor Control Center. Individuals under 18 years of age require a separate work request form.
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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
CUI
DATE: XX/XX/XXXX
MEMORANDUM FOR 20 SFS/S-5V:
(email to: BOTH Ms. Jacqueline Hernandez-Sears jacqueline.hernandez-sears.1@us.af.mil, SSgt Austin Simerly austin.simerly@us.af.mil, and Mr. Joshua
Arbeiter joshua.arbeiter.2@us.af.mil 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 and will receive a confirmation email once completed with instructions.
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) DOD EDPI: The # on the back of you CAC
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)
DOE, JOHN E. 1995/01/01 123-45-6789 SC-12345678 Y Y
********IF UNDER THE AGE OF 18, PLEASE COMPLETE A SEPARATE WORK REQUEST. *********
DO NOT FILL THIS PAGE PLEASE USE THE NEXT PAGE
DEPARTMENT OF THE AIR FORCE
20th FIGHTER WING (ACC)
SHAW AIR FORCE BASE SOUTH CAROLINA
Victory By Valor
CUI
DATE: 12-Mar-26
MEMORANDUM FOR 20 SFS/S-5V
FROM: 20th CONS
SUBJECT: Contractors need base access for site visit
WHO: Interested Vendors
WHAT FOR: Site Visit at Building 1997
WHERE: Building 1997
(If base wide give justification)
WHEN: 18 March 2026 @ 1030
SPONSOR NAME:
DOD EDPI:
CONTACT INFO:
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.
PLEASE READ THE STATEMENTS BELOW
1. 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.
2. If you, as the sponsor, filled out the request and answered N for U.S Citizen please make sure you submit scanned in documents before coming to the VCC. **i.e.-FOREIGN VISA, PERMANENT RESIDENT CARD (Form I-551) & EMPLOYMENT AUTHORIZATION CARD (Form I-766) HOLDERS, ETC.
3. AS THE SPONSOR, I will inform my visitors they must have identification in compliance with the Real ID Act OR have a Federal ID in which cases they do not. If they do not, they will not be able to receive a pass from the VCC.
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)
File details come from the government source that posted it. Updated .