ATTACHMENT 13 Visitor Request Worksheet.pdf

PDF 431 KB Posted

Attached to
145 Airlift Wing Add/Alter Small Air Terminal Building 5
Solicitation number
W50S87-21-B-5005
Issued by

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This document contains a solicitation for construction services and a visitor request worksheet for security screening. The solicitation seeks bids to add and alter a small air terminal building at the 145th Airlift Wing in North Carolina. Interested bidders must attend a mandatory pre-bid conference on June 2, 2021. The solicitation is issued by the Department of the Army North Carolina Army National Guard.

The visitor request worksheet is a form used to screen and vet non-DoD civilian visitors to the 145th Air Wing installation. The sponsor provides visitor information and the worksheet is submitted to security forces for a background check. Upon approval or denial, details are recorded and the completed worksheet is distributed to relevant parties. The form collects personal information from visitors subject to privacy laws.

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Page 1 of 2 Current as of 22 March 2021

145 SFS VISITOR'S REQUEST WORKSHEET

(THIS WORKSHEET IS SUBJECT TO THE PRIVACY ACT OF 1974)

AUTHORITY: 10 U.S.C. 8013, DODI 1000.30, AFMAN 31-101 V3, and AFI 33-332 PRINCIPLE PURPOSE(S): To conduct National Crime Information Center (NCIC) check, on non-DoD affiliated civilian visitors.

DISCLOSURE: Disclosure of requested information is voluntary. However, failure to provide information may result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the visitor's visit to the 145 AW Installation.

1. INSTRUCTIONS

All information must be completed; First, Middle, and Last Names (no initials). Email worksheet to zachary.leddy.2@us.af.mil

SECTION I: Ensure all blocks are complete.

1.1. SPONSOR'S RANK/ NAME 1.2. SPONSOR'S PHONE NUMBER & UNIT

1.3. VISITORS AFFILIATION 1.4 VISITOR'S DESTINATION & PURPOSE FOR VISIT

Visitor's Information

1.5. NAME (LAST, FIRST, MIDDLE) 1.6. SOCIAL SECURITY # 1.7. DL# & STATE 1.8. DOB 1.9. DATES & TIMES 1.10. VETTING RESULTS 1.11. VETTED BY

SECTION II: To be completed, signed, and dated by Security Forces.

2.1. DISTRIBUTION INSTRUCTIONS APPROVED and DENIED ON FITNESS CRITERIA.

Ensure all information is loaded into the Main Gate Database and completed worksheet is sent to the originator, sponsor (if different than the originator), and 145MSG.S5Pass.ID@us.af.mil

2.2. INFORMATION NEEDED FOR DENIAL ON FITNESS CRITERIA AND/OR MISCELLANEOUS COMMENTS, I.E. MAY NOT DRIVE.

Ensure full name, company, and reason for denial is placed below and/or comments if needed: Date:

mailto:usaf.nc.145-aw.list.bdoc@mail.mil mailto:usaf.nc.145-aw.list.bdoc@mail.mil

Page 2 of 2 Current as of 22 March 2021

INSTRUCTIONS FOR COMPLETING VISITOR REQUEST WORKSHEET

SECTION I TO BE COMPLETED BY SPONSOR:

Block 1.1. Enter the sponsor's Rank/Name and DOD or Social Security Number.

Block 1.2. Enter sponsor's contact number and unit.

Block 1.3. Enter company's name or visitors purpose of visiting 145th AW Installation.

Block 1.4. Enter the visitors allowed destination or destinations by sponsor and a brief description of the visitor's purpose for visit.

Block 1.5. Enter Full Last Name, Full First Name, and Full Middle Name (No Initials).

Block 1.6. Visitor's Social Security Number.

Block 1.7. Enter visitor's issued driver's license or state issued ID number and state of issue.

Block 1.8. Enter visitor’s Date of Birth.

Block 1.9. Ensure to enter the requested dates and times of the visitor.

(Note: Contractors that will need access for more than 10 cumulative days will need to complete an 145 AW Form 28.)

SECTION 1.10. & 1.11.: TO BE COMPLETED BY SFS:

Block 1.10. Ensure personnel are vetted via NCIC and CJLEADS. Vetting results will be annotated by APPROVED or DENIED.

Block 1.11. SFS personnel conducting the vetting will place their initials in this block.

SECTION II: TO BE COMPLETED, SIGNED, AND DATED BY SFS:

Block 2.1. Ensure all information is loaded into the Main Gate Database and completed worksheet is sent to the originator, sponsor (if different than the originator), and 145MSG.S5Pass.ID@us.af.mil

Block 2.2. This section will be used to annotate the reason for the denial, if visitor is denied, and/or any other pass-on information on the visitor, i.e. may not drive due to invalid driver’s license etc.

(Note: SFS member conducting the vetting will need to sign and date the completed form, Section II, Block 2.2.)

This spreadsheet contains FOR OFFICIAL USE ONLY (FOUO) information which must be protected under the Freedom of Information Act (5 U.S.C. 552) and/or the Privacy Act of 1974 (5 U.S.C. 552a). Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in disciplinary action, criminal and/or civil penalties. Further distribution is prohibited without the approval of the author of this worksheet unless the recipient has a need to know in the performance of official duties. If you have received this worksheet in error, please notify the sender and delete all copies of this worksheet. This worksheet contains FOR OFFICIAL USE ONLY (FOUO) information which must be protected under the Freedom of Information Act (5 U.S.C. 552) and/or the Privacy Act of 1974 (5 U.S.C. 552a).

Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in disciplinary action, criminal and/or civil penalties. Further distribution is prohibited without the approval of the author of this worksheet unless the recipient has a need to know in the performance of official duties. If you have received this worksheet in error, please notify the sender and delete all copies of this worksheet.

mailto:usaf.nc.145-aw.list.bdoc@mail.mil

SECTION I TO BE COMPLETED BY SPONSOR:
Block 1.1. Enter the sponsor's Rank/Name and DOD or Social Security Number.
Block 1.3. Enter company's name of visitor being sponsored, if applicable, and/or any additional comments.
Block 1.7. Enter visitor's issued driver's license or state issued ID number and state of issue.
APPROVED or DENIED.
18 DOBRow6:
Row5:
110 VETTING RESULTSRow6:
1101 VETTED BYRow6:
15 NAME LAST FIRST MIDDLERow7:
16 SOCIAL SECURITY Row7:
17 DL STATERow7:
18 DOBRow7:
Row6:
110 VETTING RESULTSRow7:
1101 VETTED BYRow7:
15 NAME LAST FIRST MIDDLERow8:
16 SOCIAL SECURITY Row8:
17 DL STATERow8:
18 DOBRow8:
Row7:
110 VETTING RESULTSRow8:
1101 VETTED BYRow8:
15 NAME LAST FIRST MIDDLERow9:
16 SOCIAL SECURITY Row9:
17 DL STATERow9:
18 DOBRow9:
Row8:
110 VETTING RESULTSRow9:
1101 VETTED BYRow9:
15 NAME LAST FIRST MIDDLERow10:
16 SOCIAL SECURITY Row10:
17 DL STATERow10:
18 DOBRow10:
Row9:
110 VETTING RESULTSRow10:
1101 VETTED BYRow10:
15 NAME LAST FIRST MIDDLERow11:
16 SOCIAL SECURITY Row11:
17 DL STATERow11:
18 DOBRow11:
Row10:
110 VETTING RESULTSRow11:
1101 VETTED BYRow11:
15 NAME LAST FIRST MIDDLERow12:
16 SOCIAL SECURITY Row12:
17 DL STATERow12:
18 DOBRow12:
Row11:
110 VETTING RESULTSRow12:
1101 VETTED BYRow12:
15 NAME LAST FIRST MIDDLERow13:
16 SOCIAL SECURITY Row13:
17 DL STATERow13:
18 DOBRow13:
Row12:
110 VETTING RESULTSRow13:
1101 VETTED BYRow13:
15 NAME LAST FIRST MIDDLERow14:
16 SOCIAL SECURITY Row14:
17 DL STATERow14:
18 DOBRow14:
Row13:
110 VETTING RESULTSRow14:
1101 VETTED BYRow14:
15 NAME LAST FIRST MIDDLERow15:
16 SOCIAL SECURITY Row15:
17 DL STATERow15:
18 DOBRow15:
Row14:
110 VETTING RESULTSRow15:
1101 VETTED BYRow15:
15 NAME LAST FIRST MIDDLERow16:
16 SOCIAL SECURITY Row16:
17 DL STATERow16:
18 DOBRow16:
Row15:
110 VETTING RESULTSRow16:
1101 VETTED BYRow16:
15 NAME LAST FIRST MIDDLERow17:
16 SOCIAL SECURITY Row17:
17 DL STATERow17:
18 DOBRow17:
Row16:
110 VETTING RESULTSRow17:
1101 VETTED BYRow17:
15 NAME LAST FIRST MIDDLERow18:
16 SOCIAL SECURITY Row18:
17 DL STATERow18:
18 DOBRow18:
Row17:
110 VETTING RESULTSRow18:
1101 VETTED BYRow18:
15 NAME LAST FIRST MIDDLERow19:
16 SOCIAL SECURITY Row19:
17 DL STATERow19:
18 DOBRow19:
Row18:
110 VETTING RESULTSRow19:
1101 VETTED BYRow19:
15 NAME LAST FIRST MIDDLERow20:
16 SOCIAL SECURITY Row20:
17 DL STATERow20:
18 DOBRow20:
Row19:
110 VETTING RESULTSRow20:
1101 VETTED BYRow20:
15 NAME LAST FIRST MIDDLERow21:
16 SOCIAL SECURITY Row21:
17 DL STATERow21:
18 DOBRow21:
Row20:
110 VETTING RESULTSRow21:
1101 VETTED BYRow21:
15 NAME LAST FIRST MIDDLERow22:
16 SOCIAL SECURITY Row22:
17 DL STATERow22:
18 DOBRow22:
Row21:
110 VETTING RESULTSRow22:
1101 VETTED BYRow22:
15 NAME LAST FIRST MIDDLERow23:
16 SOCIAL SECURITY Row23:
17 DL STATERow23:
18 DOBRow23:
Row22:
110 VETTING RESULTSRow23:
1101 VETTED BYRow23:
15 NAME LAST FIRST MIDDLERow24:
16 SOCIAL SECURITY Row24:
17 DL STATERow24:
18 DOBRow24:
Row23:
110 VETTING RESULTSRow24:
1101 VETTED BYRow24:
15 NAME LAST FIRST MIDDLERow25:
16 SOCIAL SECURITY Row25:
17 DL STATERow25:
18 DOBRow25:
Row24:
110 VETTING RESULTSRow25:
1101 VETTED BYRow25:
15 NAME LAST FIRST MIDDLERow26:
16 SOCIAL SECURITY Row26:
17 DL STATERow26:
18 DOBRow26:
Row25:
110 VETTING RESULTSRow26:
1101 VETTED BYRow26:
Text 2: (703) 391-4207
Text 1: SMSgt Bryant K Alexander
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1102 date:
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File details come from the government source that posted it. Updated .