Attachment 5 - Fort Lee Access Request Form.pdf

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Attached to
Fort Lee Job Order Contract (JOC)
Solicitation number
W91QF5-19-R-0008
Issued by

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This document includes a request form and federal contract opportunity notice. The request form is for background checks and access credentials for groups visiting Fort Lee, Virginia for purposes such as site visits, family events, or graduations. It outlines requirements for sponsors and contracting officer representatives to submit personal information for clearance applicants.

The related federal contract covers job order contracting services at Fort Lee. The Mission and Installation Contracting Command at Fort Eustis is soliciting proposals for an indefinite delivery, indefinite quantity contract with a twelve-month base period and four optional one-year extensions. Services include sustainment, maintenance, repair, and minor construction for facilities such as offices, medical sites, classrooms, and utilities. The NAICS code is 236220 and small business size standard is $36.5 million. Questions are due by April 20, 2020 to the specified contracting staff.

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Request for Background Check and Access Credential

(Utilize for Group/Family/Graduation and Special Event access requests)

Company / Event: Sponsor / COR Name: Phone:

Gov. Organization: Contract Number: Start Date: End Date:

Last Name First Name MI Sex Date of Birth SSN DL / ID # State Expiration

Visitor Control Center Use Status Print Name

1. I certify that all information contained on this application has been verified.

2. All individuals contained on this application do not require a DoD Common Access Card (CAC). Sponsor / COR Signature:

DES FORM 190-2, APR 2018 (PREVIOUS EDITION IS OBSOLETE)

DPW PSO/Access Control Officer:

DES FORM 190-2, Group Application Instruction

DES Form 190-2 is utilized to apply for background checks and issuance of long term access credentials for a group of employees, working for a single company under a single contract. This form may also be used for group requests such as family visits, graduations and special event access requests.

For short term individual submissions use DES Form 190-3

This form is to be used by the COR (Contracting Officer's Representative) or GES (Government Employee Sponsor) for requests performing official business to organizations / tenant activities on Fort Lee and for the Sponsor for group family visit, graduation and special event access requests.

DO NOT HAVE THIS FORM PASSED FROM PERSON TO PERSON

This form contains privacy act information, and must be protected.

The COR / GES / Sponsor must collect this information and fill in the form.

The COR / GES / Sponsor must ensure individuals providing the information are aware of the privacy act statement

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY: Title 5, USC 3331, 552, 552a; 10 USC 10204; Executive Orders (EO) 10450, 10865, and 12333.

PRINCIPAL PURPOSE: The information requested is for the purpose of granting access to the Fort Lee Installatio n.

ROUTINE USES: Basis for determinatio n of qualifications and background informatio n for eligibility for access to Fort Lee Installation. The Social Security Number (SSN), required for record accuracy, is requested pursuant to EO 9397.

DISCLOSUR E: Providing requested information, to include your SSN is voluntary. However, your access may not be granted if all requested information is not provided.

Contents shall not be disclosed, discussed, or shared with individuals unless they have a direct need-to-know in performance of their official duties. Deliver this document directly to the intended recipient. DO NOT drop off or send to a third-party. This document contains personal or privileged informatio n and should be treated as "For Official Use Only (FOUO)".

It is the COR / GES responsibility to ensure proper notification is given when any person or company is no longer serving in the capacity indicated in the request.

NOTE: Access credentials will be issued for a period not exceeding the lessor of:

a) 1 year

b) Expiration of contract

c) Expiration date of the ID of the individual.

d) Duration of visit (family, graduation and/or special event)

Submission:

The DES Form 190-2 can be submitted through the following two (2) methods:

1. The COR / GES / Sponsor can digitally sign the form and send request encrypted from their “.mil” email account.

a. Mail to: usarmy.lee.imcom.list.des-access-control-forms-submissions@mail.mil

2. Sign the form and personally hand deliver it.

DES FORM 190-2, APR 2018 (PREVIOUS EDITION IS OBSOLETE) Page 2 of 2 mailto:usarmy.lee.imcom.list.des-access-control-forms-submissions@mail.mil

Company Event: Fort Lee, VA (JOC) "Site Visit"
Sponsor COR Name:
Phone:
Start Date: 4/16/2020
End Date: 4/17/2020
Last NameRow1:
First NameRow1:
MIRow1:
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Organization: Directorate of Public Works
Contract Number:

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