Attachment 3 -Sioan 380-2 Personal Data Questionnaire.pdf
PDF 160 KB Posted
- Attached to
- Shop Towel Service Federal contract opportunity
- Solicitation number
- W911KF-23-Q-0018
About this file
This document contains a personal data questionnaire and certification form required for individuals seeking unescorted access to the Anniston Army Depot. The form requests information such as the individual's name, Social Security number, citizenship status, physical description, driver's license and address history. It must be completed in person along with proof of U.S. citizenship if applicable, and certified by an authorized personnel representative. Approval or denial of unescorted access is contingent upon submission of a completed form.
The related federal contract opportunity is a solicitation issued by the Department of the Army Materiel Command Contracting Command Detroit Arsenal. It seeks provision of all labor, equipment, materials and transportation necessary for the contractor to pick up soiled shop towels from inventory points across the Anniston Army Depot on a predetermined basis. The contractor must clean the towels according to the standards outlined in the statement of work and return cleaned towels to designated locations to maintain adequate supply levels. Replacement of lost, torn or damaged towels with new towels is also required on a weekly basis not to exceed 10% of towels cleaned without authorization.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| W911KF-23-Q-0018 0002.pdf | ||
| Revised Attachment 4- Pricing Spreadsheet.xlsx | XLSX spreadsheet | |
| W911KF-23-Q-0018 0001.pdf | ||
| Attachment 2 -Evidence of Authority To Sign Offers.pdf | ||
| Attachment 4- Pricing Spreadsheet.xlsx | XLSX spreadsheet | |
| W911KF-23-Q-0018 Shop Towel Service.pdf | ||
| Attachment 1- Statement of Work (SOW).pdf | ||
| Attachment 5-Wage Determination 2015-4587-Rev No 21.pdf | ||
| Attachment 6- Past Performance Questionnaire-.pdf |
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Text version
Request Recurring: Yes / No PERSONAL DATA QUESTIONNAIRE – (See AR 380-67 for use of this form; proponent is AMSTA-AN-ESP)
CONTRACTOR COMPANY NAME (Prime) WORK PHONE
SUBCONTRACTOR NAME CONTRACT NUMBER CONTRACT EXPIRES
INDIVIDUAL’S NAME (First name, Middle name, Last name) ***NO INITIALS *** SSN
OTHER NAMES USED (INCLUDE FORMER MARRIED NAMES) TYPE BADGE/AREA:
DATE OF BIRTH PLACE OF BIRTH CITIZENSHIP
MONTH DAY YEAR CITY COUNTY STATE
*** NOTE ***IF YOU WERE BORN OUTSIDE OF THE UNITED STATES, YOU MUST FURNISH PROOF OF U.S.
CITIZENSHIP UPON SUBMISSION OF THIS FORM TO THIS INSTALLATION. PROOF OF U.S. CITIZENSHIP MUST BE SUBMITTED IN PERSON BY THE INDIVIDUAL, ALONG WITH THIS FORM, TO THE BADGE OFFICE, PHYSICAL SECURITY DIVISION, DES.
PHYSICAL DESCRIPTION COLOR EYES COLOR HAIR HEIGHT WEIGHT SEX RACE
DRIVERS LICENSE NO STATE OF ISSUE OR STATE IDENTIFICATION NO. STATE OF ISSUE
ADDRESSES FOR THE PAST FIVE (5) YEARS, INCLUDING PRESENT ADDRESS: (STREET, CITY, COUNTY, STATE)
1. 4.
(County) (County)
2. 5.
(County) (County)
3. 6.
(County) (County)
AUTHORITY: Internal Security Act of 1950 (50 USC 797); Executive Order 9397. PRINCIPAL PURPOSE: To document information necessary for selection, assignment or termination for persons desiring entry to all, or parts, of Anniston Army Depot.
ROUTINE USES: The information provided will be furnished to the Directorate of Emergency Services at Anniston Army Depot; to officials within the Department of Defense who have a need for it to perform official business. NATURE OF DISCLOSURE:
Disclosure of the requested information is voluntary. Failure to provide the information, however, may result in being denied unescorted access to the installation.
LEGAL SIGNATURE OF INDIVIDUAL REQUESTING ACCESS: DATE
********************** CERTIFICATION **********************
I certify that the individual named above is, in fact, an employee of the company as listed above. I understand that a knowing and willful false statement can be punished by fine or imprisonment, or both. (U.S. Code, title 18 USC 1001)
SIGNATURE OF AUTHORIZED PERSONNEL/REPRESENTATIVE DATE
DO NOT WRITE BELOW THIS LINE
DISAPPROVED SIGNATURE OF DISAPPROVING OFFICIAL DATE
APPROVED
____ PHOTOGRAPHIC BADGE
____ NON-PHOTOGRAPHIC BADGE – NO ESCORT REQUIRED
____ NON-PHOTOGRAPHIC BADGE - ESCORT REQUIRED
NO DRIVING PRIVILEGES
Badge Office Issues Letter
SIGNATURE OF APPROVING OFFICIAL: DATE
SIOAN Form 380-2, Rev 11 Mar 08 PREVIOUS EDITIONS OBSOLETE
| SSN |
| TYPE BADGE/AREA: |
| CITIZENSHIP |
| PLACE OF BIRTH |
| DATE OF BIRTH |
| STATE |
| COUNTY |
| CITY |
| YEAR |
| DAY |
| MONTH |
| *** NOTE ***IF YOU WERE BORN OUTSIDE OF THE UNITED STATES, YOU MUST FURNISH PROOF OF U.S. CITIZENSHIP UPON SUBMISSION OF THIS FORM TO THIS INSTALLATION. PROOF OF U.S. CITIZENSHIP MUST BE SUBMITTED IN PERSON BY THE INDIVIDUAL, ALONG WITH THIS FORM, TO THE BADGE OFFICE, PHYSICAL SECURITY DIVISION, DES. |
| HEIGHT |
| WEIGHT |
| SEX |
| RACE |
| PHYSICAL DESCRIPTION |
| COLOR EYES |
| COLOR HAIR |
| OR |
| STATE OF ISSUE |
| STATE IDENTIFICATION NO. |
| STATE OF ISSUE |
| DRIVERS LICENSE NO. |
| ADDRESSES FOR THE PAST FIVE (5) YEARS, INCLUDING PRESENT ADDRESS: (STREET, CITY, COUNTY, STATE) |
| 4. |
| 1. |
| (County) |
| 5. |
| (County) |
| 6. |
| (County) |
| AUTHORITY: Internal Security Act of 1950 (50 USC 797); Executive Order 9397. PRINCIPAL PURPOSE: To document information necessary for selection, assignment or termination for persons desiring entry to all, or parts, of Anniston Army Depot. ROUTINE USES: The information provided will be furnished to the Directorate of Emergency Services at Anniston Army Depot; to officials within the Department of Defense who have a need for it to perform official business. NATURE OF DISCLOSURE: Disclosure of the requested information is voluntary. Failure to provide the information, however, may result in being denied unescorted access to the installation. |
| DATE |
| LEGAL SIGNATURE OF INDIVIDUAL REQUESTING ACCESS: |
| ********************** CERTIFICATION ********************** |
| DATE |
| SIGNATURE OF AUTHORIZED PERSONNEL/REPRESENTATIVE |
| DO NOT WRITE BELOW THIS LINE |
| DISAPPROVED |
| DATE |
| SIGNATURE OF DISAPPROVING OFFICIAL |
| NO DRIVING PRIVILEGES |
| APPROVED |
| DATE |
| SIGNATURE OF APPROVING OFFICIAL: |
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