ATTACH 8_GAP blank form.pdf

PDF 339 KB Posted Sep 6, 2022

Attached to: TERMITE PEST CONTROL SERVICES AT MCB CAMP SMEDLEY D. BUTLER, OKINAWA, JAPAN
Solicitation number: N4008422T2203
Issued by: Department of the Navy Naval Facilities Engineering Command

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Other files

File	Type	Posted
N4008422T2203_Amend 0001.pdf	PDF	Sep 27, 2022
N4008422T2203_RFQ.pdf	PDF	Sep 9, 2022
N4008422T2203_RFQ.pdf	PDF	Sep 6, 2022
ATTACH 4_Past Performance Questionnaire.docx	DOCX document	Sep 6, 2022
ATTACH 9_Before_Starting_Business_with_NAVFAC_JUN2021.pdf	PDF	Sep 6, 2022
ATTACH 7_Site Visit Location.pdf	PDF	Sep 6, 2022
ATTACH 5_Pre Proposal Inquiry Form.xlsx	XLSX spreadsheet	Sep 6, 2022
ATTACH 6_Site Visit_Request_Form.xlsx	XLSX spreadsheet	Sep 6, 2022

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MCIPAC-MCBB GROUP ACCESS PASS ESCORTED (ｴｽｺｰﾄが必要) ADMIN NO.

FORM MUST BE TYPED - NO ADDITIONS WILL BE ACCEPTED ONCE APPROVED

Kinser Foster/Lester Courtney/McTureous Hansen Schwab Futenma

Sponsor Name (スポンサー)(Last, First, MI) Rank Duty Phone Unit/Organization

As the sponsor, I understand the guidelines below and that I am responsible for my guests' conduct at ALL times while aboard the installation.

X Sponsor’s Signature

* Persons under the age of 18 must be accompanied by their parent/guardian, or have in their possession a signed Permission Slip. 入域者が18歳未満の場

合は保護者または世話人が同行するもしくは入域についての委任状が必要。* If the number of visitors exceeds the space allotted, a separate request must be submitted for remaining group members. 入域者の人数が以下の欄に入らない場合は別紙に記載すること。* This form is not valid for Designated Third Country Nationals (USFJI 31-204). この書式は指定された第3国の者には適用されない。* Individuals must possess a suitable means of identification while on or attempting to gain access to the area(s) listed herein. Failure to do so may result in the denial of access or removal from the area. 入域者はここに記載されている場所に入域する、又はしている間は身分証明書を形態すること。これに反した場合、入域を却下されたり、又は退去を命じられることもある.

DO NOT MARK BELOW THIS LINE

Dates Authorized（期間） Gate(s) Authorized（通行許可されたゲート） Approval Signature (米軍側サイン) to Times Authorized（時間）

Not Valid Without Original Signature & Stamp Access may be authorized by the Camp Commander to or his/her designated representative ONLY

PRIVACY SENSITIVE: This form may contain personal data or legally privileged information protected from disclosure by the Freedom of Information Act (FOIA), 5 USC Section 552, and/or the Privacy Act, 5 USC Section 552a. Reviewing, copying, distributing, or otherwise disseminating this form is strictly prohibited without the recipient having a valid need to know in the performance of official duties or the express permission of the sender. If you have received this document in error, please notify the owner/creator or your Privacy Act Officer immediately.

ANY MISUSE OR UNAUTHORIZED DISCLOSURE MAY RESULT IN BOTH CIVIL AND CRIMINAL PENALTIES.

MCIPAC-MCBB/G-3 5/PMO/5512/1 (05-20) PREVIOUS EDITIONS ARE OBSOLETE LiveCycle Designer ES4

Visitor（訪問者） Vehicle (車両) Last Name* First Name* Citizenship* Age

(if <18) Make Model Color License Plate*

Purpose of Visit Destination

Dates/times Requested Gates Requested

Kinser

11.0.0.20130303.1.892433

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ADMIN NO:

undefined:

Kinser: Off

Foster: Off

Courtney: Off

Hansen: Off

Schwab: Off

Futenma: Off

Sponsor Name (スポンサー） (Last, First, MI):

Rank:

Duty Phone:

Unit/Organization:

Purpose of Visit:

Destination:

Dates/times Requested:

Gates Requested:

Sponsor's Signature:

Last Name:

First Name*_Row_1:

Citizenship*_Row_1:

Age (if <18)_Row_1:

Make_Row_1:

Model_Row_1:

Color_Row_1:

License Plate*_Row_1:

Last Name:

First Name*_Row_2:

Citizenship*_Row_2:

Age (if <18)_Row_2:

Make_Row_2:

Model_Row_2:

Color_Row_2:

License Plate*_Row_2:

Last Name:

First Name*_Row_3:

Citizenship*_Row_3:

Age (if <18)_Row_3:

Make_Row_3:

Model_Row_3:

Color_Row_3:

License Plate*_Row_3:

Last Name:

First Name*_Row_4:

Citizenship*_Row_4:

Age (if <18)_Row_4:

Make_Row_4:

Model_Row_4:

Color_Row_4:

License Plate*_Row_4:

Last Name:

First Name*_Row_5:

Citizenship*_Row_5:

Age (if <18)_Row_5:

Make_Row_5:

Model_Row_5:

Color_Row_5:

License Plate*_Row_5:

Last Name:

First Name*_Row_6:

Citizenship*_Row_6:

Age (if <18)_Row_6:

Make_Row_6:

Model_Row_6:

Color_Row_6:

License Plate*_Row_6:

Last Name:

First Name*_Row_7:

Citizenship*_Row_7:

Age (if <18)_Row_7:

Make_Row_7:

Model_Row_7:

Color_Row_7:

License Plate*_Row_7:

Last Name:

First Name*_Row_8:

Citizenship*_Row_8:

Age (if <18)_Row_8:

Make_Row_8:

Model_Row_8:

Color_Row_8:

License Plate*_Row_8:

Last Name:

First Name*_Row_9:

Citizenship*_Row_9:

Age (if <18)_Row_9:

Make_Row_9:

Model_Row_9:

Color_Row_9:

License Plate*_Row_9:

Last Name:

First Name*_Row_10:

Citizenship*_Row_10:

Age (if <18)_Row_10:

Make_Row_10:

Model_Row_10:

Color_Row_10:

License Plate*_Row_10:

Last Name:

First Name*_Row_11:

Citizenship*_Row_11:

Age (if <18)_Row_11:

Make_Row_11:

Model_Row_11:

Color_Row_11:

License Plate*_Row_11:

Last Name:

First Name*_Row_12:

Citizenship*_Row_12:

Age (if <18)_Row_12:

Make_Row_12:

Model_Row_12:

Color_Row_12:

License Plate*_Row_12:

Last Name:

First Name*_Row_13:

Citizenship*_Row_13:

Age (if <18)_Row_13:

Make_Row_13:

Model_Row_13:

Color_Row_13:

License Plate*_Row_13:

Last Name:

First Name*_Row_14:

Citizenship*_Row_14:

Age (if <18)_Row_14:

Make_Row_14:

Model_Row_14:

Color_Row_14:

License Plate*_Row_14:

Last Name:

First Name*_Row_15:

Citizenship*_Row_15:

Age (if <18)_Row_15:

Make_Row_15:

Model_Row_15:

Color_Row_15:

License Plate*_Row_15:

Last Name:

First Name*_Row_16:

Citizenship*_Row_16:

Age (if <18)_Row_16:

Make_Row_16:

Model_Row_16:

Color_Row_16:

License Plate*_Row_16:

Last Name:

First Name*_Row_17:

Citizenship*_Row_17:

Age (if <18)_Row_17:

Make_Row_17:

Model_Row_17:

Color_Row_17:

License Plate*_Row_17:

Last Name:

First Name*_Row_18:

Citizenship*_Row_18:

Age (if <18)_Row_18:

Make_Row_18:

Model_Row_18:

Color_Row_18:

License Plate*_Row_18:

Last Name:

First Name*_Row_19:

Citizenship*_Row_19:

Age (if <18)_Row_19:

Make_Row_19:

Model_Row_19:

Color_Row_19:

License Plate*_Row_19:

Last Name:

First Name*_Row_20:

Citizenship*_Row_20:

Age (if <18)_Row_20:

Make_Row_20:

Model_Row_20:

Color_Row_20:

License Plate*_Row_20:

Dates Authorized:

to:

times Authorized:

to:

Gate(s) Authorized:

Approval Signature:

SubmitButton1:

File details come from the government source that posted it. Updated Sep 6, 2022.