Attachment 2 - 55 SFS CONTRACTORVENDOR NCIC SCREENING PASS REQUEST.pdf
PDF 250 KB Posted
- Attached to
- B1000 Carpet Replacement
- Solicitation number
- FA460026Q0109
About this file
This is a template form for contractor/vendor NCIC (National Crime Information Center) screening and pass request processing at Offutt Air Force Base. The spreadsheet is designed to collect personnel information from contractor and vendor companies requiring base access and to facilitate security clearance screening through the 55th Security Forces Squadron (55 SFS).
The form requires submission of contractor and vendor employee data including full name, date of birth, driver's license or state ID number, Social Security Number, work schedule, employment dates, and country of citizenship. The requesting company must provide organizational details such as company name, address, and a company representative point of contact. The form must be signed by the Unit Commander or Security Manager and, for non-U.S. citizens, requires additional authorization from 55 WG/IP (55th Wing Intelligence & Plans). All listed personnel must present a REAL ID Act-compliant driver's license, state ID, or approved alternate photo identification upon arrival at Offutt AFB Visitor Control Center. The spreadsheet contains Controlled Unclassified Information (CUI) protected under the Freedom of Information Act and Privacy Act, with distribution restricted to individuals with a need-to-know basis. The point of contact for CUI matters is Mr. Gregory Derkatch at (402) 232-7339.
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Text version
Contract#:
Contract Start/End Dates: Unit Commander or Security Manager Sig Block
NOTE:
Security Manager will ensure all listed personnel are briefed that they must present a REAL ID ACT compliant driver’s license, or state ID, or an approved alternate form of photo identification upon arrival at Offutt AFB Visitor Control Center.
CUI
55 SFS CONTRACTOR/VENDOR NCIC SCREENING & PASS REQUEST SPREADSHEET
CUI
Contractor/ Vendor NCIC Screening & Pass Request Spreadsheet contain “CONTROLLED UNCLASSIFED INFORMATION” (CUI) 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 message unless the recipient has a need to know in the performance of official duties. CONTROLLED BY: 55SFS/MAP/CUI CATEGORY: PRVCY/DISTRIBUTION/DISSEMINATION CONTROL: FEDCON POC: MR.
DERKATCH, GREGORY (402) 232-7339.
Offutt AFB Sponsoring Agency / Unit: Company Name:
Base Sponsor's Name: Company Address:
Base Sponsor's Phone #: Company Representative Name:
Request Date: Company Representative Phone Number:
Full Name Date of Birth Work Schedule Country of Last, First, MI Year Month Day Drivers License/ID # State SSAN Days Hrs Start Date - End Date (MMDDYYYY) Citizenship
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Contract Start/End Dates: Unit Commander or Security Manager Sig Block 55 WG/IP Sig Block - Needed For Non U.S. Visitors
Contract Start/End Dates: Unit Commander or Security Manager Sig Block 55 WG/IP Sig Block - Needed For Non U.S. Visitors
File details come from the government source that posted it. Updated .