Attachment 4 SFS Form 3_EAL Request.pdf

181 KB Posted

Attached to
OH ANG Rickenbacker Outbound Gate Repair
Solicitation number
W50S8P-23-B-0003
Issued by

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This document is a contractor and visitor request form requiring personal information for individuals requiring access to a controlled unclassified information site. It requests information such as full name, Social Security number, driver's license details, company affiliation, job site, and dates of access. The form requires a signature from the sponsoring organization with their contact details and must be approved by security forces personnel before an employee or visitor is granted a controlled access level.

The related federal contract opportunity is a solicitation from the Department of the Army National Guard to repair the outbound gate at Rickenbacker Air National Guard Base in Ohio. Solicitation number W50S8P-23-B-0003 has been issued for the OH ANG Rickenbacker Outbound Gate Repair project. Responses are due based on the standard solicitation schedule.

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Other files

File Type Posted
OF1419 Outbound Gate.pdf PDF
W50S8P-23-B-0003-0001 Amendment 2.pdf PDF
RFI Responses 08.11.2023_W50S8P23B0003.pdf PDF
Attachment 2 Combined Drawing Gate 06.26.2023.pdf PDF
W50S8P-23-B-0003-0001 Amendment 1.pdf PDF
W50S8P-23-B-0003 Solicitation.pdf PDF
Attachment 2 Combined Drawing Gate 06.26.2023.pdf PDF
Attachment 1 Statement of Work_NLZG222005_05.30.2023.docx DOCX document
W50S8P-23-B-0001 Solicitation.pdf PDF
Attachment 3 RFI.docx DOCX document

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CUI

121 SFS Form 3 (Nov 2021)

Controlled By:

CUI Category: PRVY Dissemination: FEDCON

POC:

CUI

EAL# 121 SFS CONTRACTOR/VISITOR REQUEST

CONTROLLED UNCLASSIFIED INFORMATION (CUI) This document contains information that must be protected under the Privacy ACT OF 1974 (See AFI 33-332) and protected from disclosure under the Freedom, of Information Act, 5 USC 552. Do not release outside of DoD channels without the consent of the originator’s office.

SSN: Mandatory for all unescorted entries. Escorts must be provided by the sponsoring organization for all personnel with missing information or the inability to validate the credentials.

DISCLOSURE IS VOLUNTARY; however, failure to disclose required information will prohibit unescorted access. Failure to provide complete and accurate information will delay the processing of this request.

EMPLOYEE/VISITOR INFORMATION BACKGROUND

CHECK

LAST FIRST MI SSN DRIVERS

LIC #

STATE COMPANY/ORG JOB

SITE

START

DATE

END

DATE

DATE METHOD

NOTES:

SPONSOR INFORMATION

NAME/RANK ORGANIZATION PHONE EMAIL DATE SIGNATURE

SECURITY FORCES USE ONLY

OFFICER NAME/RANK DATE SIGNATURE DENIED CONTRACTOR/ VISITOR

EAL:
EMPLOYEEVISITOR INFORMATION:
LASTRow1:
FIRSTRow1:
MIRow1:
SSNRow1:
DRIVERS LIC Row1:
STATERow1:
COMPANYORGRow1:
JOB SITERow1:
START DATERow1:
END DATERow1:
DATERow1:
METHODRow1:
LASTRow2:
FIRSTRow2:
MIRow2:
SSNRow2:
DRIVERS LIC Row2:
STATERow2:
COMPANYORGRow2:
JOB SITERow2:
START DATERow2:
END DATERow2:
DATERow2:
METHODRow2:
LASTRow3:
FIRSTRow3:
MIRow3:
SSNRow3:
DRIVERS LIC Row3:
STATERow3:
COMPANYORGRow3:
JOB SITERow3:
START DATERow3:
END DATERow3:
DATERow3:
METHODRow3:
LASTRow4:
FIRSTRow4:
MIRow4:
SSNRow4:
DRIVERS LIC Row4:
STATERow4:
COMPANYORGRow4:
JOB SITERow4:
START DATERow4:
END DATERow4:
DATERow4:
METHODRow4:
LASTRow5:
FIRSTRow5:
MIRow5:
SSNRow5:
DRIVERS LIC Row5:
STATERow5:
COMPANYORGRow5:
JOB SITERow5:
START DATERow5:
END DATERow5:
DATERow5:
METHODRow5:
LASTRow6:
FIRSTRow6:
MIRow6:
SSNRow6:
DRIVERS LIC Row6:
STATERow6:
COMPANYORGRow6:
JOB SITERow6:
START DATERow6:
END DATERow6:
DATERow6:
METHODRow6:
LASTRow7:
FIRSTRow7:
MIRow7:
SSNRow7:
DRIVERS LIC Row7:
STATERow7:
COMPANYORGRow7:
JOB SITERow7:
START DATERow7:
END DATERow7:
DATERow7:
METHODRow7:
LASTRow8:
FIRSTRow8:
MIRow8:
SSNRow8:
DRIVERS LIC Row8:
STATERow8:
COMPANYORGRow8:
JOB SITERow8:
START DATERow8:
END DATERow8:
DATERow8:
METHODRow8:
LASTRow9:
FIRSTRow9:
MIRow9:
SSNRow9:
DRIVERS LIC Row9:
STATERow9:
COMPANYORGRow9:
JOB SITERow9:
START DATERow9:
END DATERow9:
DATERow9:
METHODRow9:
LASTRow10:
FIRSTRow10:
MIRow10:
SSNRow10:
DRIVERS LIC Row10:
STATERow10:
COMPANYORGRow10:
JOB SITERow10:
START DATERow10:
END DATERow10:
DATERow10:
METHODRow10:
NOTES:
NAMERANKRow1:
ORGANIZATIONRow1:
PHONERow1:
EMAILRow1:
DATERow1_2:
SIGNATURERow1:
OFFICER NAMERANKRow1:
DATERow1_3:
SIGNATURERow1_2:
DENIED CONTRACTOR VISITORRow1:
Text1:
Text2:

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