Attachment 3 WSMR Installation Access NCIC Form 300.pdf

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Attached to
WSMR Contracted Security Guards
Solicitation number
W911SG24R0021
Issued by

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This document is a White Sands Missile Range (WSMR) Installation Access NCIC-III Check Request form. It outlines the process for individuals to obtain access to WSMR, including providing personal information such as legal name, driver's license, and social security number to conduct a criminal background check. The form requires a sponsor, their contact information, and the purpose for access. It specifies that if the access is for a contract purpose, the sponsor will be the Contracting Officer's Representative (COR).

The related federal contract opportunity is a solicitation (W911SG24R0021) for WSMR Contracted Security Guards. The Department of the Army Materiel Command Mission and Installation Contracting Command Fort Hood has a requirement from the WSMR Department of Emergency Services to provide security guard services, including planning, scheduling, report preparation, record keeping, and quality control. The contractor must provide an adequately qualified staff of contract security guards to perform the required duties outlined in the Performance Work Statement.

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White Sands Missile Range Installation Access NCIC-III Check Request Prescribing Regulation: Army Regulation 190-13

Proponent: Directorate of Emergency Services-Physical Security Privacy Act Statement

AUTHORITY: 10 U.S.C. 3013; 44 U.S.C. 3103; and Army Regulation 190-13, Army Physical Security Program.

PRINCIPAL PURPOSE: To determine suitability of individual(s) requesting access to White Sands Missile Range. This information will be used to generate state and federal criminal history record 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 White Sands Missile Range.

DISCLOSURE: Voluntary. However, failure to provide information could result in the refusal to access White Sands Missile Range.

Legal Name as Appears on Driver’s License or State

ID.

Example: John Robert Doe

M 15-APR-75 D01234567 NM 123-45-6789 08-AUG-24 09-AUG-24 MON-FRI

0700-1600 BLDG 465 PDC DES PS USE

ONLY

Last Name First Name Middle

Name or NA if none

Sex

(M/F) DOB

Driver’s License Number

Driver’s License

State

Social Security Number

Begin Date End Date

Work Access Hours

Work Area/ Visit

Location Org.

Name

Clear/Denied/

NMI

(DES PS USE

ONLY)

Sponsor Phone: Sponsor Email:

Purpose for access:

Sponsor Name:

Sponsor Organization: Sponsor Signature:

When complete submit to: usarmy.wsmr.imcom.mbx.physical-sec@army.mil (DES USE ONLY) NCIC-III Check Date NCIC-III Check Complete

Remarks Block: please ensure all fields below are filled out in their entirety.

** Note: If access to WSMR is for contract purpose, Sponsor will be the COR.

WSMR FORM 300 JULY 2024

Last NameRow1:
First NameRow1:
Middle Name or NA if noneRow1:
Drivers License NumberRow1:
Drivers License StateRow1:
Social Security NumberRow1:
Work Access HoursRow1:
Work Area Visit LocationRow1:
Org NameRow1:
Last NameRow2:
First NameRow2:
Middle Name or NA if noneRow2:
Drivers License NumberRow2:
Drivers License StateRow2:
Social Security NumberRow2:
Work Access HoursRow2:
Work Area Visit LocationRow2:
Org NameRow2:
Last NameRow3:
First NameRow3:
Middle Name or NA if noneRow3:
Drivers License NumberRow3:
Drivers License StateRow3:
Social Security NumberRow3:
Work Access HoursRow3:
Work Area Visit LocationRow3:
Org NameRow3:
Last NameRow4:
First NameRow4:
Middle Name or NA if noneRow4:
Drivers License NumberRow4:
Drivers License StateRow4:
Social Security NumberRow4:
Work Access HoursRow4:
Work Area Visit LocationRow4:
Org NameRow4:
Last NameRow5:
First NameRow5:
Middle Name or NA if noneRow5:
Drivers License NumberRow5:
Drivers License StateRow5:
Social Security NumberRow5:
Work Access HoursRow5:
Work Area Visit LocationRow5:
Org NameRow5:
Last NameRow6:
First NameRow6:
Middle Name or NA if noneRow6:
Drivers License NumberRow6:
Drivers License StateRow6:
Social Security NumberRow6:
Work Access HoursRow6:
Work Area Visit LocationRow6:
Org NameRow6:
Last NameRow7:
First NameRow7:
Middle Name or NA if noneRow7:
Drivers License NumberRow7:
Drivers License StateRow7:
Social Security NumberRow7:
Work Access HoursRow7:
Work Area Visit LocationRow7:
Org NameRow7:
Last NameRow8:
First NameRow8:
Middle Name or NA if noneRow8:
Drivers License NumberRow8:
Drivers License StateRow8:
Social Security NumberRow8:
Work Access HoursRow8:
Work Area Visit LocationRow8:
Org NameRow8:
Last NameRow9:
First NameRow9:
Middle Name or NA if noneRow9:
Drivers License NumberRow9:
Drivers License StateRow9:
Social Security NumberRow9:
Work Access HoursRow9:
Work Area Visit LocationRow9:
Org NameRow9:
Last NameRow10:
First NameRow10:
Middle Name or NA if noneRow10:
Drivers License NumberRow10:
Drivers License StateRow10:
Social Security NumberRow10:
Work Access HoursRow10:
Work Area Visit LocationRow10:
Org NameRow10:
Last NameRow11:
First NameRow11:
Middle Name or NA if noneRow11:
Drivers License NumberRow11:
Drivers License StateRow11:
Social Security NumberRow11:
Work Access HoursRow11:
Work Area Visit LocationRow11:
Org NameRow11:
Last NameRow12:
First NameRow12:
Middle Name or NA if noneRow12:
Drivers License NumberRow12:
Drivers License StateRow12:
Social Security NumberRow12:
Work Access HoursRow12:
Work Area Visit LocationRow12:
Org NameRow12:
Check Box7: Off
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Text8: Site Visit for WSMR Contracted Security Guards
Text9: Thomas Benavidez
Text10: 575-678-8602
Text11: thomas.r.benavidez.civ@army.mil
Text12: DES PSD

File details come from the government source that posted it. Updated .