Attachment 4_SIOAN Form 380-2 Personnel Data Questionnaire.pdf

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