Attachment 3_ SIOAN Form 380-2 Personnel Data Questionnaire.doc
DOC document 58 KB Posted
- Attached to
- EMCS Federal contract opportunity
- Solicitation number
- W911KF-22-Q-0011
About this file
This document contains a personnel data questionnaire form and information about a related sole source federal contract opportunity. The form collects personal information from individuals requiring access to Anniston Army Depot, including name, Social Security number, citizenship status, physical description, addresses for the past five years, and certification by an authorized personnel representative. The related sole source contract opportunity is for the daily maintenance of the existing Energy Management Controls System at Anniston Army Depot by Alabama Controls through September 2023. It is a base year contract with four option years issued by the Department of the Army Materiel Command Contracting Command Detroit Arsenal.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Attachment 1_Evidence of Authority To Sign Offers.pdf | ||
| Attachment 2_Wage Determination.pdf | ||
| Attachment 4_ACC-ANAD COVID Letter.pdf | ||
| W911KF22Q0011.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
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