Attachment 11- CUI JBAB Base Access Registration Form.xlsx
XLSX spreadsheet 17 KB Posted
- Attached to
- Flooring IDIQ Federal contract opportunity
- Solicitation number
- FA706022R00
- Issued by
- Department of the Air Force
About this file
This document contains a Joint Base Anacostia-Bolling base access registration form and details for a flooring indefinite delivery indefinite quantity (IDIQ) contract opportunity with the Department of the Air Force. The registration form collects applicant information such as name, date of birth, citizenship status, identification documents, employer information, and requires authorization for background checks. It is used to control physical access to Department of Defense facilities under the jurisdiction of the 11th Security Forces Squadron. The flooring IDIQ opportunity seeks to establish multiple IDIQ contracts for flooring services worldwide. Pricing will be obtained through task orders that will be competed amongst IDIQ holders. Responses are due by the date specified in the solicitation issued under number FA706022R0031.
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Text version
Sheet1
| CUI JOINT BASE ANACOSTIA-BOLLING BASE ACCESS REGISTRATION FORM | |||||||
| PLEASE COMPLETE BOTH SIDES OF FORM | |||||||
| PRIVACY ACT STATEMENT: This information is protected under the Privacy Act of 1974. This form will be considered confidential when filled out. | |||||||
| AUTHORITY: 10 U.S.C., Department of Defense Manual (DoDM) 5200.08 Volume 3, AFMAN 31-101_Volume 3 I.A.C. & AFI 31-101 Integrated Defense | |||||||
| PURPOSE(S): To control physical access to Department of Defense facilities over which the 11th Security Forces Squadron has law enforcement jurisdiction. | |||||||
| ROUTINE USE(S): To designated contractors, Federal agencies, and foreign officials for the purpose of granting access to this DOD/USAF installation. | |||||||
| DISCLOSURE: | Providing registration information is voluntary. Failure to provide requested information may result in denial of access to this installation. | ||||||
| APPLICANT INFORMATION | |||||||
| 1. LAST NAME | 2. FIRST NAME | 3. MIDDLE NAME | 4. SUFFIX | ||||
| 5. GENDER (CIRCLE ONE) MALE OR FEMALE | 6. SOCIAL SECURITY NUMBER | 7. DATE OF BIRTH | 8. CITY/STATE OF BIRTH | 9. COUNTRY OF BIRTH | |||
| 10. U.S. CITIZEN (CIRCLE ONE) | YES | NO | 11. CITIZENSHIP, IF NOT U.S. (COUNTRY) |
12. WEIGHT (POUNDS) 13. HEIGHT (INCHES) 14. HAIR COLOR 15. EYE COLOR
| 16. HOME ADDRESS (INCLUDE CITY, STATE, ZIP CODE) | 17. CELL/HOME PHONE | ||||
| IDENTIFICATION DOCUMENTS | |||||
| 18. STATE ID/DRIVER'S LICENSE NUMBER | 19. STATE ISSUED | 20. DATE ISSUED | 21. DATE EXPIRES | ||
| 22. PASSPORT NUMBER | 23. COUNTRY ISSUED | 24. DATE ISSUED | 25. DATE EXPIRES | ||
| 26. GREEN CARD NUMBER | |||||
| 27. DATE ISSUED | 28. DATE EXPIRES | ||||
| 29. OTHER APPROVED IDENTIFICATION: | 30. DATE ISSUED | 31. DATE EXPIRES | |||
| FOR CONTRACTORS/SERVICE/VENDOR PROVIDERS: EMPLOYMENT ACTIVITY INFORMATION | |||||
| 32. EMPLOYER NAME AND ADDRESS (INCLUDE CITY/STATE/ZIP CODE) | 33. EMPLOYER PHONE NUMBER | ||||
| 34. SUPERVISOR NAME AND ADDRESS (INCLUDE CITY/STATE/ZIP CODE): | 35. SUPERVISOR PHONE NUMBER | ||||
| REQUIREMENT TO RETURN JBAB BASE ACCESS CREDENTIALS | |||||
| 36. I UNDERSTAND THAT I AM REQUIRED TO RETURN MY JBAB ISSUED BASE ACCESS CREDENTIAL TO THE JOINT VISITOR CONTROL CENTER WHEN IT EXPIRES OR IF MY EMPLOYMENT IS TERMINATED FOR ANY REASON. | INITIAL: ____________ | ||||
| AUTHORIZATION/RELEASE: | |||||
| 37. I hereby authorize the USAF/DoD and other authorized Federal agencies to obtain any information required from the Federal government and/or state agencies, including but not limited to , the Federal Bureau of Investigation (FBI), the Defense Security Service (DSS), & the U.S. Department of Homeland Security (DHS). I have been notified of USAF right to perform minimal vetting and fitness determination as a condition of access to DOD/USAF installations. I understand that I may request a record identifier; the source of the record and that I may obtain records from the state Law Enforcement Office as may be available to me under the law. I also understand that this information will be confidential. | |||||
| RELEASE (CONT.) AND CERTIFICATION | |||||
| 38. I release any individual, including records custodians, any component of the U.S. Government or the individual State Criminal History Repository supplying information, from all liability for damages that may result on account of compliance, or any attempts to to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representatives of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me. |
FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD RESULT IN FINES AND/OR IMPRISONMENT UP TO 5 YRS.
CAREFULLY REVIEW THE FORM BEFORE SIGNING TO ENSURE ALL REQUIRED BLOCKS ARE COMPLETED.
| I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE BY ME ON THIS FORM ARE | 1 Day Pass Request: 7 July 2022 from 7 AM to 12 PM | |
| TRUE, COMPLETE AND CORRECT. | DDF | |
| 39. SPONSOR/AGENCY Demetria Figueroa/ 11 CONS | ||
| 40. SPONSOR DoDI NUMBER 1015379193 | 41. SPONSOR PHONE NUMBER 202-284-3361 | |
| CRIMINAL HISTORY BACKGROUND CHECK IS REQUIRED FOR BASE ACCESS | ||
| I have been advised of the required criminal history background check and give my consent by providing my signature in this block. |
DATE: ________________ SIGNATURE: ______________________________________
| CRIMINAL HISTORY | |||
| 42. WERE YOU EVER CONVICTED OF A FELONY? | YES | NO | INITIAL: ____________ |
| COMPLETED BY JOINT VISITOR CENTER PERSONNEL | ||||
| 43. INFORMATION VERIFIED BY | 44. DBIDS OPERATOR | 45. VALID REGISTRATION | 46. VEHICLE INSURANCE | |
| 47. BACKGROUND (OpenFox) PERFORMED BY | 48. RESULTS OF BACKGROUND CHECK | |||
| 49. VETTED DATE | 50. VETTED EXPIRATION DATE | |||
| 51. DURATION | PAPER | CARD | 52. PASS ISSUED/EXPIRATION DATES | |
| 53. APPROVED |
| Perimeter Access Control 27-Feb-2020 |
| FOR OFFICIAL USE ONLY |
&F
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