attachment-2-bid-3016-25.pdf

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CONTRACT: HIGH VOLTAGE ELECTRICAL SERVICES
Solicitation number
Bid 3016-25
Issued by
Rockingham County, New Hampshire

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This document is a Contractor Entry Pass Application form for the 157th Air Refueling Wing at Pease Air National Guard Base in New Hampshire, issued in conjunction with the state's procurement of high voltage electrical services (Contract 3016-25). The form serves as the security vetting mechanism for contractor personnel seeking unescorted access to the installation. The application requires submission of comprehensive personal information including name, social security number, driver's license information, date of birth, and the specific areas or buildings requiring access, along with pass expiration dates. Contractors must submit the completed form, accompanied by a formal contractor application, to 157th Security Forces Squadron at least seven days prior to the issuance of a DBIDS badge. A mandatory site visitation is scheduled for March 25, 2025, at 8:00 AM, with the bid closing deadline set for April 11, 2025, at 11:00 AM Eastern Time. The contract term extends from Governor and Executive Council approval through May 31, 2030, with potential extension options for up to two additional years.

The security vetting process outlined in the accompanying memorandum dated May 9, 2024, delegates fitness determination authority to the 157th Security Forces Squadron, which conducts criminal record checks through the National Crime Information Center and Interstate Identification Index databases. Applicants must provide one of three acceptable forms of identification: a REAL ID, a passport, or a state-issued ID combined with a birth certificate and social security card presented at time of arrival. Disqualifying factors include terrorist affiliations, inability to verify identity, prior barring from federal installations, wanted status by any law enforcement agency, convictions for specified serious crimes including espionage, terrorism, murder, sexual assault, firearms violations, drug distribution, and for contractors specifically, felony-level charges pending court adjudication. Disqualified individuals may appeal determinations through the Installation Commander or Mission Support Group Commander, though they remain prohibited from unescorted installation entry during any appeal period. The form accommodates multiple contractor personnel entries across multiple pages, facilitating batch submissions for organizations with multiple workers requiring base access.

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CONTRACTOR ENTRY PASS APPLICATION

157th Air Refueling Wing

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 message unless the recipient has a need to know in the performance of official duties.

As of: 6 November 2017 (Previous Editions Obsolete)

COMPANY INFORMATION

Company Name: Tel #:

Address: City: State: Zip:

Prime Contractor Contact Person: Tel #:

Pease ANGB Sponsor: Organization: Tel #:

INDIVIDUAL INFORMATION

NAME SOCIAL SECURITY

NUMBER

DRIVER’S LICENSE/ID

NUMBER

DATE OF BIRTH

(MM/DD/YY)

ACCESS TO

AREA/BLDG

PASS EXPIRATION

DATE (MM/DD/YY)

CONTRACTOR ENTRY PASS APPLICATION

157th Air Refueling Wing

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 message unless the recipient has a need to know in the performance of official duties.

As of: 6 November 2017 (Previous Editions Obsolete)

NAME SOCIAL SECURITY

NUMBER

DRIVER’S LICENSE/ID

NUMBER

DATE OF BIRTH

(MM/DD/YY)

ACCESS TO

AREA/BLDG

PASS EXPIRATION

DATE (DD/MM/YY)

(Last, First, MI)

(If applicable)

State:

Date of request:

Name:

Maiden Name:

DOB:

SSN:

Drivers License #

Are you a U.S. Citizen ______Yes ______No If no, provide copy of foreign passport

Reason for requesting access:

Contractor/DBIDS Pass Delivery/Service Provider

Veteran’s Clinic Access

___Long term visitor

AUTHORIZATION AND RELEASE

I hereby direct and authorize the 157th Air Refueling Wing to perform a record check of my person through the National

Crime Information Center and Interstate Identification Index databases in order to determine my fitness for unescorted entry onto the installation of Pease Air National Guard Base.

I hereby release the 157th Air Refueling Wing, the State of New Hampshire, and the United States Air Force from any causes of action of any kind, nature, or description whatsoever, arising from the release of, or request for, my criminal record history.

X

Signature of Applicant

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 message unless the recipient has a need to know in the performance of official duties.

“Citizen soldiers building the nation’s most respected Air National Guard Unit-serving America, New Hampshire, and community..in partnership with family and employer.”

Current As of 14 Sep 2023 (Previous Editions Obsolete)

Approved

Denied Signature: Opr:

Signature: IEC:

SECURITY FORCESUSE ONLY

Must provide one of the following acceptable forms of ID;

1. REAL ID, or 2.

3.

PASSPORT, or STATE ISSUED ID and BIRTH CERTIFICATE and SSN CARD

(Requester must provide the above documents at the time of arrival)

NEW HAMPSHIRE AIR NATIONAL GUARD

157TH SECURITY FORCES SQUADRON

PEASE AIR NATIONAL GUARD BASE NEW HAMPSHIRE

For proper vetting, this form must be completed and accompanied with a contractor application and submitted to Security Forces by an authorized sponsor to;

157.ARW.SFS.CSS.Org@us.af.mil 7 days prior to issue of DBIDS badge.

“Citizen soldiers building the nation’s most respected Air National Guard Unit – serving America, New Hampshire, and community…in partnership with family and employer.”

9 May 2024

MEMORANDUM FOR 157 SFS/CC

FROM: 157 ARW/CC

SUBJECT: Vetting and Fitness Determination of Individuals Permitted Access to the

Installation

Reference: DoDM5200.08V3_DAFMAN31-101V3_DAFGM2023-01, Installation Perimeter

Access Control, 5 Jun 23

1. The 157th Air Refueling Wing Installation Commander has delegated to 157th Security Forces Squadron (SFS) the task of vetting/fitness determinations for the 157th Air Refueling Wing and Pease Air National Guard Base (DAFMAN 31-101v.3, Installation Perimeter Access Control, 5 Jun 23).

2. Visitors to the installation will be vetted IAW with the standards in DAFMAN 31-101v.3, para. 3.1.. This includes contractors; delivery/service providers; Portsmouth Community Based Outpatient Clinic (CBOC) employees, patients and guests; and long term visitors. The criminal record check necessary for visitors to have unescorted access to the installation will requested by the visitor on the Fitness Determination Criminal Record Check Request form attached.

3. CBOC employees, patients and those who accompany patients will be vetted IAW DAFMAN 31-101v.3, para. 5.1.C(4). Vetted patients of the CBOC may be accompanied by up to five vetted visitors.

4. Minors under the age of 18 accompanying vetted CBOC patients will be allowed access without vetting (DAFMAN 31-101v.3, para. 3.1.A(4)).

5. Visitors will be disqualified IAW DAFMAN 31-101v.3, para.3.3, as follows:

a. The individual is known to be or reasonably suspected of being a terrorist or belongs to an organization with known terrorism links/support.

b. The installation is unable to verify the individual's claimed identity.

c. The individual has previously been barred from access to a federal installation or stand-alone facility.

d. The individual is wanted by Federal, State, Local, or other civil law enforcement authorities, regardless of offense or violation.

NEW HAMPSHIRE AIR NATIONAL GUARD

HEADQUARTERS 157TH AIR REFUELING WING

PEASE AIR NATIONAL GUARD BASE NEW HAMPSHIRE

“Citizen soldiers building the nation’s most respected Air National Guard Unit – serving America, New Hampshire, and community…in partnership with family and employer.”

e. The individual has any conviction for espionage, sabotage, treason, terrorism, or murder.

f. The individual’s name appears on any Federal or State agency’s watch list or hit list for criminal behavior or terrorist activity.

g. The individual has been convicted of a firearms or explosive violation.

h. The individual has been convicted of sexual assault, armed robbery, rape, child molestation, child pornography, trafficking in humans, drug possession with intent to sell, or drug distribution.

i. The individual has knowingly and willfully engaged in acts or activities designed to overthrow the U.S. Government by force.

j. The individual has exhibited behavior or has a criminal record summary that cause concern for the health, safety or welfare of personnel on the installation, or that cause concern for the physical security or environment of the base. If an individual is disqualified under this criteria, a member of the 157 SFS will provide written documentation to support its determination to be maintained on file to be reviewed in the event of appeal.

k. [CONTRACTOR ONLY] The individual has felony level charges pending court adjudication for criteria under paragraph 5 which would otherwise be disqualifying. The individual may re-apply for installation access upon providing proof of charge disposition.

6. Disqualified visitors may appeal the vetting determination through the Installation Commander or the Mission Support Group Commander.

7. Individuals disqualified from entry will not be authorized to enter the installation without escort, including during the period of any pending appeal.

NELSON E. PERRON, Colonel, NHANG Commander, 157th Air Refueling Wing

Attachment:

Fitness Determination Criminal Record Check Request form cc:

157 MSG/CC

157 ARW/SJA

Contractor Entry Pass Application.pdf
Vetting Form Sep 2023.pdf
Fitness Determination 5-9-24 (CC Signed).pdf
NEW HAMPSHIRE AIR NATIONAL GUARD
Company Name:
Tel:
Address:
City:
Zip:
Prime Contractor Contact Person:
Tel_2:
Organization:
Tel_3:
NAMERow1:
SOCIAL SECURITY NUMBERRow1:
SOCIAL SECURITY NUMBERRow1_2:
SOCIAL SECURITY NUMBERRow1_3:
DRIVERS LICENSEID NUMBERRow1:
DATE OF BIRTH MMDDYYRow1:
DATE OF BIRTH MMDDYYRow1_2:
DATE OF BIRTH MMDDYYRow1_3:
ACCESS TO AREABLDGRow1:
PASS EXPIRATION DATE DDMMYYRow1:
PASS EXPIRATION DATE DDMMYYRow1_2:
PASS EXPIRATION DATE DDMMYYRow1_3:
NAMERow2:
SOCIAL SECURITY NUMBERRow2:
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DRIVERS LICENSEID NUMBERRow2:
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PASS EXPIRATION DATE DDMMYYRow2_2:
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NAMERow3:
SOCIAL SECURITY NUMBERRow3:
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DRIVERS LICENSEID NUMBERRow3:
DATE OF BIRTH MMDDYYRow3:
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PASS EXPIRATION DATE DDMMYYRow3_3:
NAMERow4:
SOCIAL SECURITY NUMBERRow4:
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DRIVERS LICENSEID NUMBERRow4:
DATE OF BIRTH MMDDYYRow4:
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PASS EXPIRATION DATE DDMMYYRow4_3:
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SOCIAL SECURITY NUMBERRow5:
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DRIVERS LICENSEID NUMBERRow5:
DATE OF BIRTH MMDDYYRow5:
DATE OF BIRTH MMDDYYRow5_2:
DATE OF BIRTH MMDDYYRow5_3:
ACCESS TO AREABLDGRow5:
PASS EXPIRATION DATE DDMMYYRow5:
PASS EXPIRATION DATE DDMMYYRow5_2:
PASS EXPIRATION DATE DDMMYYRow5_3:
NAMERow6:
SOCIAL SECURITY NUMBERRow6:
SOCIAL SECURITY NUMBERRow6_2:
SOCIAL SECURITY NUMBERRow6_3:
DRIVERS LICENSEID NUMBERRow6:
DATE OF BIRTH MMDDYYRow6:
DATE OF BIRTH MMDDYYRow6_2:
DATE OF BIRTH MMDDYYRow6_3:
ACCESS TO AREABLDGRow6:
PASS EXPIRATION DATE DDMMYYRow6:
PASS EXPIRATION DATE DDMMYYRow6_2:
PASS EXPIRATION DATE DDMMYYRow6_3:
NAMERow7:
SOCIAL SECURITY NUMBERRow7:
SOCIAL SECURITY NUMBERRow7_2:
SOCIAL SECURITY NUMBERRow7_3:
DRIVERS LICENSEID NUMBERRow7:
DATE OF BIRTH MMDDYYRow7:
DATE OF BIRTH MMDDYYRow7_2:
DATE OF BIRTH MMDDYYRow7_3:
ACCESS TO AREABLDGRow7:
PASS EXPIRATION DATE DDMMYYRow7:
PASS EXPIRATION DATE DDMMYYRow7_2:
PASS EXPIRATION DATE DDMMYYRow7_3:
NAMERow8:
SOCIAL SECURITY NUMBERRow8:
SOCIAL SECURITY NUMBERRow8_2:
SOCIAL SECURITY NUMBERRow8_3:
DRIVERS LICENSEID NUMBERRow8:
DATE OF BIRTH MMDDYYRow8:
DATE OF BIRTH MMDDYYRow8_2:
DATE OF BIRTH MMDDYYRow8_3:
ACCESS TO AREABLDGRow8:
PASS EXPIRATION DATE DDMMYYRow8:
PASS EXPIRATION DATE DDMMYYRow8_2:
PASS EXPIRATION DATE DDMMYYRow8_3:
NAMERow9:
SOCIAL SECURITY NUMBERRow9:
SOCIAL SECURITY NUMBERRow9_2:
SOCIAL SECURITY NUMBERRow9_3:
DRIVERS LICENSEID NUMBERRow9:
DATE OF BIRTH MMDDYYRow9:
DATE OF BIRTH MMDDYYRow9_2:
DATE OF BIRTH MMDDYYRow9_3:
ACCESS TO AREABLDGRow9:
PASS EXPIRATION DATE DDMMYYRow9:
PASS EXPIRATION DATE DDMMYYRow9_2:
PASS EXPIRATION DATE DDMMYYRow9_3:
NAMERow10:
SOCIAL SECURITY NUMBERRow10:
SOCIAL SECURITY NUMBERRow10_2:
SOCIAL SECURITY NUMBERRow10_3:
DRIVERS LICENSEID NUMBERRow10:
DATE OF BIRTH MMDDYYRow10:
DATE OF BIRTH MMDDYYRow10_2:
DATE OF BIRTH MMDDYYRow10_3:
ACCESS TO AREABLDGRow10:
PASS EXPIRATION DATE DDMMYYRow10:
PASS EXPIRATION DATE DDMMYYRow10_2:
PASS EXPIRATION DATE DDMMYYRow10_3:
NAMERow1_2:
SOCIAL SECURITY NUMBERRow1_4:
SOCIAL SECURITY NUMBERRow1_5:
SOCIAL SECURITY NUMBERRow1_6:
DRIVERS LICENSEID NUMBERRow1_2:
DATE OF BIRTH MMDDYYRow1_4:
DATE OF BIRTH MMDDYYRow1_5:
DATE OF BIRTH MMDDYYRow1_6:
ACCESS TO AREABLDGRow1_2:
PASS EXPIRATION DATE DDMMYYRow1_4:
PASS EXPIRATION DATE DDMMYYRow1_5:
PASS EXPIRATION DATE DDMMYYRow1_6:
NAMERow2_2:
SOCIAL SECURITY NUMBERRow2_4:
SOCIAL SECURITY NUMBERRow2_5:
SOCIAL SECURITY NUMBERRow2_6:
DRIVERS LICENSEID NUMBERRow2_2:
DATE OF BIRTH MMDDYYRow2_4:
DATE OF BIRTH MMDDYYRow2_5:
DATE OF BIRTH MMDDYYRow2_6:
ACCESS TO AREABLDGRow2_2:
PASS EXPIRATION DATE DDMMYYRow2_4:
PASS EXPIRATION DATE DDMMYYRow2_5:
PASS EXPIRATION DATE DDMMYYRow2_6:
NAMERow3_2:
SOCIAL SECURITY NUMBERRow3_4:
SOCIAL SECURITY NUMBERRow3_5:
SOCIAL SECURITY NUMBERRow3_6:
DRIVERS LICENSEID NUMBERRow3_2:
DATE OF BIRTH MMDDYYRow3_4:
DATE OF BIRTH MMDDYYRow3_5:
DATE OF BIRTH MMDDYYRow3_6:
ACCESS TO AREABLDGRow3_2:
PASS EXPIRATION DATE DDMMYYRow3_4:
PASS EXPIRATION DATE DDMMYYRow3_5:
PASS EXPIRATION DATE DDMMYYRow3_6:
NAMERow4_2:
SOCIAL SECURITY NUMBERRow4_4:
SOCIAL SECURITY NUMBERRow4_5:
SOCIAL SECURITY NUMBERRow4_6:
DRIVERS LICENSEID NUMBERRow4_2:
DATE OF BIRTH MMDDYYRow4_4:
DATE OF BIRTH MMDDYYRow4_5:
DATE OF BIRTH MMDDYYRow4_6:
ACCESS TO AREABLDGRow4_2:
PASS EXPIRATION DATE DDMMYYRow4_4:
PASS EXPIRATION DATE DDMMYYRow4_5:
PASS EXPIRATION DATE DDMMYYRow4_6:
NAMERow5_2:
SOCIAL SECURITY NUMBERRow5_4:
SOCIAL SECURITY NUMBERRow5_5:
SOCIAL SECURITY NUMBERRow5_6:
DRIVERS LICENSEID NUMBERRow5_2:
DATE OF BIRTH MMDDYYRow5_4:
DATE OF BIRTH MMDDYYRow5_5:
DATE OF BIRTH MMDDYYRow5_6:
ACCESS TO AREABLDGRow5_2:
PASS EXPIRATION DATE DDMMYYRow5_4:
PASS EXPIRATION DATE DDMMYYRow5_5:
PASS EXPIRATION DATE DDMMYYRow5_6:
NAMERow6_2:
SOCIAL SECURITY NUMBERRow6_4:
SOCIAL SECURITY NUMBERRow6_5:
SOCIAL SECURITY NUMBERRow6_6:
DRIVERS LICENSEID NUMBERRow6_2:
DATE OF BIRTH MMDDYYRow6_4:
DATE OF BIRTH MMDDYYRow6_5:
DATE OF BIRTH MMDDYYRow6_6:
ACCESS TO AREABLDGRow6_2:
PASS EXPIRATION DATE DDMMYYRow6_4:
PASS EXPIRATION DATE DDMMYYRow6_5:
PASS EXPIRATION DATE DDMMYYRow6_6:
NAMERow7_2:
SOCIAL SECURITY NUMBERRow7_4:
SOCIAL SECURITY NUMBERRow7_5:
SOCIAL SECURITY NUMBERRow7_6:
DRIVERS LICENSEID NUMBERRow7_2:
DATE OF BIRTH MMDDYYRow7_4:
DATE OF BIRTH MMDDYYRow7_5:
DATE OF BIRTH MMDDYYRow7_6:
ACCESS TO AREABLDGRow7_2:
PASS EXPIRATION DATE DDMMYYRow7_4:
PASS EXPIRATION DATE DDMMYYRow7_5:
PASS EXPIRATION DATE DDMMYYRow7_6:
NAMERow8_2:
SOCIAL SECURITY NUMBERRow8_4:
SOCIAL SECURITY NUMBERRow8_5:
SOCIAL SECURITY NUMBERRow8_6:
DRIVERS LICENSEID NUMBERRow8_2:
DATE OF BIRTH MMDDYYRow8_4:
DATE OF BIRTH MMDDYYRow8_5:
DATE OF BIRTH MMDDYYRow8_6:
ACCESS TO AREABLDGRow8_2:
PASS EXPIRATION DATE DDMMYYRow8_4:
PASS EXPIRATION DATE DDMMYYRow8_5:
PASS EXPIRATION DATE DDMMYYRow8_6:
NAMERow9_2:
SOCIAL SECURITY NUMBERRow9_4:
SOCIAL SECURITY NUMBERRow9_5:
SOCIAL SECURITY NUMBERRow9_6:
DRIVERS LICENSEID NUMBERRow9_2:
DATE OF BIRTH MMDDYYRow9_4:
DATE OF BIRTH MMDDYYRow9_5:
DATE OF BIRTH MMDDYYRow9_6:
ACCESS TO AREABLDGRow9_2:
PASS EXPIRATION DATE DDMMYYRow9_4:
PASS EXPIRATION DATE DDMMYYRow9_5:
PASS EXPIRATION DATE DDMMYYRow9_6:
NAMERow10_2:
SOCIAL SECURITY NUMBERRow10_4:
SOCIAL SECURITY NUMBERRow10_5:
SOCIAL SECURITY NUMBERRow10_6:
DRIVERS LICENSEID NUMBERRow10_2:
DATE OF BIRTH MMDDYYRow10_4:
DATE OF BIRTH MMDDYYRow10_5:
DATE OF BIRTH MMDDYYRow10_6:
ACCESS TO AREABLDGRow10_2:
PASS EXPIRATION DATE DDMMYYRow10_4:
PASS EXPIRATION DATE DDMMYYRow10_5:
PASS EXPIRATION DATE DDMMYYRow10_6:
NAMERow11:
SOCIAL SECURITY NUMBERRow11:
SOCIAL SECURITY NUMBERRow11_2:
SOCIAL SECURITY NUMBERRow11_3:
DRIVERS LICENSEID NUMBERRow11:
DATE OF BIRTH MMDDYYRow11:
DATE OF BIRTH MMDDYYRow11_2:
DATE OF BIRTH MMDDYYRow11_3:
ACCESS TO AREABLDGRow11:
PASS EXPIRATION DATE DDMMYYRow11:
PASS EXPIRATION DATE DDMMYYRow11_2:
PASS EXPIRATION DATE DDMMYYRow11_3:
NAMERow12:
SOCIAL SECURITY NUMBERRow12:
SOCIAL SECURITY NUMBERRow12_2:
SOCIAL SECURITY NUMBERRow12_3:
DRIVERS LICENSEID NUMBERRow12:
DATE OF BIRTH MMDDYYRow12:
DATE OF BIRTH MMDDYYRow12_2:
DATE OF BIRTH MMDDYYRow12_3:
ACCESS TO AREABLDGRow12:
PASS EXPIRATION DATE DDMMYYRow12:
PASS EXPIRATION DATE DDMMYYRow12_2:
PASS EXPIRATION DATE DDMMYYRow12_3:
NAMERow13:
SOCIAL SECURITY NUMBERRow13:
SOCIAL SECURITY NUMBERRow13_2:
SOCIAL SECURITY NUMBERRow13_3:
DRIVERS LICENSEID NUMBERRow13:
DATE OF BIRTH MMDDYYRow13:
DATE OF BIRTH MMDDYYRow13_2:
DATE OF BIRTH MMDDYYRow13_3:
ACCESS TO AREABLDGRow13:
PASS EXPIRATION DATE DDMMYYRow13:
PASS EXPIRATION DATE DDMMYYRow13_2:
PASS EXPIRATION DATE DDMMYYRow13_3:
NAMERow14:
SOCIAL SECURITY NUMBERRow14:
SOCIAL SECURITY NUMBERRow14_2:
SOCIAL SECURITY NUMBERRow14_3:
DRIVERS LICENSEID NUMBERRow14:
DATE OF BIRTH MMDDYYRow14:
DATE OF BIRTH MMDDYYRow14_2:
DATE OF BIRTH MMDDYYRow14_3:
ACCESS TO AREABLDGRow14:
PASS EXPIRATION DATE DDMMYYRow14:
PASS EXPIRATION DATE DDMMYYRow14_2:
PASS EXPIRATION DATE DDMMYYRow14_3:
NAMERow15:
SOCIAL SECURITY NUMBERRow15:
SOCIAL SECURITY NUMBERRow15_2:
SOCIAL SECURITY NUMBERRow15_3:
DRIVERS LICENSEID NUMBERRow15:
DATE OF BIRTH MMDDYYRow15:
DATE OF BIRTH MMDDYYRow15_2:
DATE OF BIRTH MMDDYYRow15_3:
ACCESS TO AREABLDGRow15:
PASS EXPIRATION DATE DDMMYYRow15:
PASS EXPIRATION DATE DDMMYYRow15_2:
PASS EXPIRATION DATE DDMMYYRow15_3:
NAMERow16:
SOCIAL SECURITY NUMBERRow16:
SOCIAL SECURITY NUMBERRow16_2:
SOCIAL SECURITY NUMBERRow16_3:
DRIVERS LICENSEID NUMBERRow16:
DATE OF BIRTH MMDDYYRow16:
DATE OF BIRTH MMDDYYRow16_2:
DATE OF BIRTH MMDDYYRow16_3:
ACCESS TO AREABLDGRow16:
PASS EXPIRATION DATE DDMMYYRow16:
PASS EXPIRATION DATE DDMMYYRow16_2:
PASS EXPIRATION DATE DDMMYYRow16_3:
Date of request:
Name:
Maiden Name:
DOB:
SSN:
Drivers License:
State:
IEC:
Opr:
Approved: Off
Denied: Off
Check Box5: Off
Check Box6: Off

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