Attachment 5 Base Pass Request.pdf

NOTE: THE INFORMATION ON THIS LETTER MUST BE LEGIBLE

MEMORANDUM FOR 23 SFS/S5; PASS AND REGISTRATION DATE: .

FROM:

(YOUR FIRM’S/PRIME CONTRACTOR'S NAME/ADDRESS)

SUBJECT: Request for Personnel Passes, Contract Number FA4830-20-S012

(INCLUDE COMPLETE CONTRACT NUMBER)

Or At the Request of 23 Contracting Squadron .

(NAME OF BASE ORGANIZATION REQUIRING CONTRACTOR’S PRESENCE ON BASE)

1. Project Title or Reason for Pass Request: Aerial Herbicide Application .

2. Please issue passes for employees of:

(YOU FIRMR YOOR UR SUBCONTRACTOR)

Employees require access to Moody AFB through:

(NOT TO EXCEED 1 YEAR)

Contractor point of contact is: - (YOUR FIRM’S REPRESENTATIVE AND PHONE NUMBER, IF CONTRACT, MUST BE PRIME CONTRACTOR)

3. If there is a contract, whether written or administered by 23 CONS or by another agency, the address above, the point of contact listed, and the signature below are with the Prime Contractor to which the contract is written. This letter will be presented for review by 23 CONS for contracts written or administered by 23 CONS and for all others will be presented for review by the base organization requesting our presence.

4. Completed, original, consent forms (no copies) to conduct criminal background will be presented for the individuals listed below.

Reviewed:

(SIGNATURE OF COMPANY OFFICIAL) (SIGNATURE OF BASE PERSONNEL)

(TYPED NAME AND TITLE OF COMPANY OFFICIAL)

Ms. Bryttanie Colletta; 229.257.4712 .

(TYPED/PRINTED NAME, PHONE NO. OF BASE PERSONNEL AND DATE)

(Format, Background Cover Letter, 02/2011) No. of Completed Consent Forms to be presented