Attachment 5 Base Access Form.pdf

PDF 431 KB Posted Jul 15, 2024

Attached to: 200RHS/DET1 Vehicle Corrosion Control Service
Solicitation number: W50S8R-24-R-5009
Issued by: Department of the Army Ohio Army National Guard

About this file

Written by GovTribe AI · Jul 15, 2024

This document is a Contractor Access Request Form for the 179th Security Forces Squadron to provide unescorted entry to a federal installation. It requires the contractor to provide personal information for each individual requesting access, including name, date of birth, social security number, and driver's license details. The contractor must agree to take responsibility for the individuals and notify them of prohibited items and activities on the installation. Access may be denied, and the contractor must notify the Security Forces if access is no longer required for any individual.

The related federal contract opportunity is for Vehicle Corrosion Control Services for the 200th Rapid Response Squadron, Detachment 1. It is a small business set-aside solicitation with a NAICS code of 811121. The contractor must be able to perform the services within 70 miles of the Mansfield, Ohio and Port Clinton, Ohio locations. The contract period of performance is from August 20, 2024 to August 19, 2025, with 12 monthly deliveries per vehicle. The contract will be awarded to the lowest priced, technically acceptable offer. Site visits are scheduled for July 25, 2024, and offerors must submit a Base Access Form at least 5 business days in advance to attend.

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CUI

Contractor Access Request Form

179th Security Forces Squadron Installation Access Section

*MUST BE DELIVERED A MINIMUM OF FIVE (5) DUTY DAYS PRIOR TO PROJECT START DATE*

Project Number Project Location Start Date End Date Last Name First Name DOB Social Security # DL State-Number Phone Number Email Address

DECLARATION OF RESPONSIBILITY: By signing below, I agree to take full responsibility for those individual(s) that I have requested unescorted entry for. I have advised the individuals listed below that the possession of illegal drugs or substances will result in prosecution by local authorities, and that no weapons are allowed onto the installation by any contractor. Weapons restrictions apply to CCW holders as well as State certified police officers unless on official duty. Violations of these prohibitions as well as base policies and procedures could result in the individual’s base access being revoked. I have advised the individuals listed below that their vehicles to include equipment, toolboxes, and personal bags such as duffel bags, backpacks, lunch boxes, etc. are subject to search upon entering and exiting the installation.

If any of the individuals listed below no longer require access prior to expiration I will notify the 179 SFS Installation Access Section. If new workers are hired, I will submit another Contractor Access Request Form no later than five (5) days prior to their start date. I understand that neither I nor any other member of my staff may escort any individual onto the installation. Individuals requiring escort must be escorted by a military member assigned to oversee the project. I understand decisions made by the 179 SFS to deny access to any individuals listed below are final and not subject to appeal and that Security Forces will not provide specific causes for denial.

SIGNATURE:

Contractor Information (All information below is required, omitting any information will result in the individual being denied access)

** For Pass & ID Use Only**

Last Name First Name MI DOB Social Security # DL State-Number VALID (Y/N) Denial Reason

PRIVACY ACT STATEMENT

PRIVACY ACT 1974: Contents shall not be disclosed, discussed, or shared with individuals unless they have direct need-to-know in the performance of their official duties. Deliver this document directly to the intended recipient. DO NOT drop off with a third-party.

AUTHORITY: AFMAN 31-101v3 PRINCIPLE PURPOSE: Collection of information to identity proof and vet for unescorted base entry. All information is for unescorted base entry purposes only.

ROUTINE USE: Local Law Enforcement DISCLOSURE IS VOLUNTARY: Disclosing is voluntary, however, failure to provide the requested information may prevent, and /or cause delay regarding a request.

Contractor Access Request Form (continuation page, attach additional pages as needed) ** For Pass & ID Use Only**

Last Name First Name MI DOB Social Security # DL State/Number VALID (Y/N) Denial Reason

PRIVACY ACT STATEMENT

AUTHORITY: AFMAN 31-101v3 PRINCIPLE PURPOSE: Collection of information to identity proof and vet for unescorted base entry. All information is for unescorted base entry purposes only.

ROUTINE USE: Local Law Enforcement DISCLOSURE IS VOLUNTARY: Disclosing is voluntary, however, failure to provide the requested information may prevent, and /or cause delay regarding a request.

Project Number:

Project Location:

Start Date:

End Date:

Last Name:

First Name:

DOB:

Social Security:

DL StateNumber:

Phone Number:

Email Address:

Last NameRow1:

First NameRow1:

MIRow1:

DOBRow1:

Social SecurityRow1:

DL StateNumberRow1:

VALID YNRow1:

Denial ReasonRow1:

Last NameRow2:

First NameRow2:

MIRow2:

DOBRow2:

Social SecurityRow2:

DL StateNumberRow2:

VALID YNRow2:

Denial ReasonRow2:

Last NameRow3:

First NameRow3:

MIRow3:

DOBRow3:

Social SecurityRow3:

DL StateNumberRow3:

VALID YNRow3:

Denial ReasonRow3:

Last NameRow4:

First NameRow4:

MIRow4:

DOBRow4:

Social SecurityRow4:

DL StateNumberRow4:

VALID YNRow4:

Denial ReasonRow4:

Last NameRow5:

First NameRow5:

MIRow5:

DOBRow5:

Social SecurityRow5:

DL StateNumberRow5:

VALID YNRow5:

Denial ReasonRow5:

Last NameRow6:

First NameRow6:

MIRow6:

DOBRow6:

Social SecurityRow6:

DL StateNumberRow6:

VALID YNRow6:

Denial ReasonRow6:

Last NameRow7:

First NameRow7:

MIRow7:

DOBRow7:

Social SecurityRow7:

DL StateNumberRow7:

VALID YNRow7:

Denial ReasonRow7:

Last NameRow1_2:

First NameRow1_2:

MIRow1_2:

DOBRow1_2:

Social SecurityRow1_2:

DL StateNumberRow1_2:

VALID YNRow1_2:

Denial ReasonRow1_2:

Last NameRow2_2:

First NameRow2_2:

MIRow2_2:

DOBRow2_2:

Social SecurityRow2_2:

DL StateNumberRow2_2:

VALID YNRow2_2:

Denial ReasonRow2_2:

Last NameRow3_2:

First NameRow3_2:

MIRow3_2:

DOBRow3_2:

Social SecurityRow3_2:

DL StateNumberRow3_2:

VALID YNRow3_2:

Denial ReasonRow3_2:

Last NameRow4_2:

First NameRow4_2:

MIRow4_2:

DOBRow4_2:

Social SecurityRow4_2:

DL StateNumberRow4_2:

VALID YNRow4_2:

Denial ReasonRow4_2:

Last NameRow5_2:

First NameRow5_2:

MIRow5_2:

DOBRow5_2:

Social SecurityRow5_2:

DL StateNumberRow5_2:

VALID YNRow5_2:

Denial ReasonRow5_2:

Last NameRow6_2:

First NameRow6_2:

MIRow6_2:

DOBRow6_2:

Social SecurityRow6_2:

DL StateNumberRow6_2:

VALID YNRow6_2:

Denial ReasonRow6_2:

Last NameRow7_2:

First NameRow7_2:

MIRow7_2:

DOBRow7_2:

Social SecurityRow7_2:

DL StateNumberRow7_2:

VALID YNRow7_2:

Denial ReasonRow7_2:

Last NameRow8:

First NameRow8:

MIRow8:

DOBRow8:

Social SecurityRow8:

DL StateNumberRow8:

VALID YNRow8:

Denial ReasonRow8:

Last NameRow9:

First NameRow9:

MIRow9:

DOBRow9:

Social SecurityRow9:

DL StateNumberRow9:

VALID YNRow9:

Denial ReasonRow9:

Last NameRow10:

First NameRow10:

MIRow10:

DOBRow10:

Social SecurityRow10:

DL StateNumberRow10:

VALID YNRow10:

Denial ReasonRow10:

Last NameRow11:

First NameRow11:

MIRow11:

DOBRow11:

Social SecurityRow11:

DL StateNumberRow11:

VALID YNRow11:

Denial ReasonRow11:

Last NameRow12:

First NameRow12:

MIRow12:

DOBRow12:

Social SecurityRow12:

DL StateNumberRow12:

VALID YNRow12:

Denial ReasonRow12:

Last NameRow13:

First NameRow13:

MIRow13:

DOBRow13:

Social SecurityRow13:

DL StateNumberRow13:

VALID YNRow13:

Denial ReasonRow13:

Last NameRow14:

First NameRow14:

MIRow14:

DOBRow14:

Social SecurityRow14:

DL StateNumberRow14:

VALID YNRow14:

Denial ReasonRow14:

Last NameRow15:

First NameRow15:

MIRow15:

DOBRow15:

Social SecurityRow15:

DL StateNumberRow15:

VALID YNRow15:

Denial ReasonRow15:

Last NameRow16:

First NameRow16:

MIRow16:

DOBRow16:

Social SecurityRow16:

DL StateNumberRow16:

VALID YNRow16:

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Last NameRow17:

First NameRow17:

MIRow17:

DOBRow17:

Social SecurityRow17:

DL StateNumberRow17:

VALID YNRow17:

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Last NameRow18:

First NameRow18:

MIRow18:

DOBRow18:

Social SecurityRow18:

DL StateNumberRow18:

VALID YNRow18:

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File details come from the government source that posted it. Updated Jul 15, 2024.