Attachment 20 FMF451 Installation Access NCIC-III Check Request .pdf
PDF 1 MB Posted
- Attached to
- Facility Maintenance Services at Fort McCoy, WI
- Solicitation number
- W912ES22R0011
About this file
This document is a template form used to request National Crime Information Center (NCIC) criminal history checks for individuals requiring access to Fort McCoy in Wisconsin. The form collects personal information such as name, date of birth, driver's license details, and intended dates and locations of access for the purpose of generating state and federal criminal history records checks to determine suitability. Required fields include legal name, sex, date of birth, driver's license number and state, begin and end dates of required access, work area and hours, company name, and purpose for access including any applicable contract number and expiration date. The sponsoring individual must be affiliated with Fort McCoy. Once completed, the form is submitted electronically to the Directorate of Emergency Services Physical Security for processing.
The related federal contract opportunity is a solicitation issued by the Department of the Army Corps of Engineers Engineering District St Paul for facility maintenance services at Fort McCoy. The contractor will provide maintenance, repairs, and preventive maintenance to enable facilities, utilities, equipment and areas to function at full capacity and for their intended use. Work includes maintenance, repair and installation of all facility and building components, devices, equipment and associated subsystems in accordance with manufacturer manuals.
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Fort McCoy Form 451 December 2021 FOUO Fort McCoy Form May 2021 Obsolete Page of AEM6.2 v11 Fort McCoy Installation Access NCIC-III Check Request Prescribing Regulation: Army Regulation 190-13, Proponent Directorate of Emergency Services
PRIVACY ACT STATEMENT AUTHORITY: The Privacy Act of 1974, Title 5 USC 552a. PRINCIPLE PURPOSE(S): To determine suitability of individual(s) requesting access to Fort McCoy. This information will be used to generate state and federal criminal history records checks. ROUTINE USE(S): Personal information may be disclosed to appropriate military and civilian emergency and investigation agencies to assist in determining suitability for access to Fort McCoy. DISCLOSURE: Voluntary; however failure to provide information will result in a refusal to grant access to Fort McCoy.
Legal Name as Appears on Driver's License or State ID. Example: John Edward Doe M 29-Apr-64 F123-4567-8912-54
WI
25-Jan-15 24-Jan-16
MON-FRI 0700-1700
Bldg 100 Commissary/TCI DES PS Use Only Last Name First Name Middle Name or NMN if none
SEX (M/F)
DOB
Drivers License Number Drivers License State Begin Date End Date Work Access Hours Work Area/ Visit Location Company Name Clear/Denied/NMI (DES PS use only) Remarks Block (At a minimum include: purpose for access; contract number and expiration date) ** Note: If access is for contract purpose, Sponsor will be the COR. In all cases, Sponsor must be affiliated with Fort McCoy.
When complete submit to: usarmy.mccoy.id-readiness.mbx.des-physical-security-iacs-form@army.mil Legal Name as Appears on Driver's License or State ID. Example: John Edward Doe M 29-Apr-64 F123-4567-8912-54
WI
25-Jan-15 24-Jan-16
MON-FRI 0700-1700 HOURS
Bldg 100 Commissary/TCI DES PS Use Only Last Name First Name Middle Name or NMN if none
SEX (M/F)
DOB
Drivers License Number Drivers License State Begin Date End Date Work Access Hours Work Area/ Visit Location Company Name Clear/Denied/NMI (DES PS use only) 11.0.0.20130303.1.892433.887364 Trudy L. Ward 20170612
DHR-ASD
Fort McCoy Installation Access NCIC-III Check Request Trudy L. Ward Fort McCoy Form 451
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