Attachment 3 SioanForm380-2 Personal Data Questionnaire.pdf
PDF 146 KB Posted
- Attached to
- Computer Numerical Controlled (CNC) Vertical Machining Centers Federal contract opportunity
- Solicitation number
- W911KF-21-Q-0032
About this file
This document contains a personal data questionnaire and instructions for obtaining access to Anniston Army Depot. The form requests personal identifying information such as name, date of birth, physical description, citizenship status, driver's license information, and residential history from individuals requiring unescorted installation access. It certifies the employment of the individual and includes approval and denial signatures. A related solicitation seeks nine computer numerical control vertical machining centers and ancillary equipment for the Army Materiel Command Contracting Command Detroit Arsenal under solicitation number W911KF-21-Q-0032 as an unrestricted procurement with a 500-employee size standard under NAICS code 333517.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| W911KF-21-Q-0032 P0001.pdf | ||
| Attachment 5 Request for Technical Literature.pdf | ||
| CNC Machining Centers Solicitation W911KF-21-Q-0032.pdf | ||
| Attachment 1 Statement of Work CNC Milling Centers.pdf | ||
| Attachment 6 Past Performance Questionnaire.pdf | ||
| Attachment 2 Evidence of Authority To Sign Offers.pdf | ||
| Attachment 4 DD Form 1423 - CNC Milling Centers.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
DO NOT WRITE BELOW THIS LINE
DISAPPROVED SIGNATURE OF DISAPPROVING OFFICIAL
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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