ATTACHMENT 4 SFS Form 3_EAL Request.pdf
PDF 181 KB Posted
- Attached to
- 3d Printer Room Upgrade Federal contract opportunity
- Solicitation number
- W50S8P24B0001
- Issued by
- Department of the Army National Guard
About this file
This document contains details for a federal construction project solicitation and a contractor visitor request form. The construction project solicitation is for modifications to an existing facility at Rickenbacker Air Base in Columbus, Ohio to accommodate a new 3D printer. The scope of work includes installing a new 50 amp power supply, additional overhead lighting, and a double-door access. The project value is between $25,000 to $100,000 and is set aside for small businesses. The contractor visitor request form requires personal information such as name, social security number, driver's license, and company information to process requests for unescorted access to federal sites.
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Text version
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
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| EMPLOYEEVISITOR INFORMATION: |
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