Attachment 4a - WSA Missile Field EAL Submittal Form - Employees Individual.pdf

Primary Contractor's Company Logo

Address:

POC Name::

POC Email:

POC Phone:

To: 5 CONS/PKA-C Submittal Section:

Attn: E-Mail:

Project: Phone:

State Issued:

Expiration of Driver License:

Real ID:

Date of Birth:

Birthplace:

Cell Phone:

Work Phone:

Employee's Name:

(Last, First Middle)

Social Security No:

DOD ID NO:(if using CAC)

Driver's License No:

701-723-2139

Applicant Information, as stated below, to be issued an ID for clearance. Please notify our office upon approval.

Date:

Line Item No:

EAL Request

Alex.Lloyd.1@us.af.mil

165 Missile Ave.

Minot AFB, ND 58705-5027

Contracting Specialist

Primary Contractor Co. Name:

Primary Contractor POC:

(Or State ID or US Passport #)E-mail: Phone #:

Sub-Contractor Co. Name:

Sub- Contractor POC:

E-mail:

Phone #:

(If No on Real ID read Note below) NoYes

1609252541C Cross-Out

FRONT BACK

Provide a legible photocopy of the employee's driver's license, state ID, or US passport or US Passport Card below:

(Also, provide below a legible photocopy of the employee's work visa / green card if not a US Citizen.)

Provide front and back of the driver's license. Keep photocopies on this page only.

Note: IDs with NOT FOR REAL ID PURPOSES or NOT FOR FEDERAL IDENTIFICATION are denied atomatically

Employee 1