Attachment 5 J-J1 PFAC Application.pdf

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HQ003421R0071 Base Operations and Support Services
Solicitation number
HQ003421R0071
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RAVEN ROCK MOUNTAIN COMPLEX

PENTAGON FACILITIES ALTERNATE CREDENTIAL (PFAC)

APPLICATION 5/2017

PRIVACY ACT STATEMENT: AUTHORITY: 10 U.S.C. 8012,44 U.S.C. 3101 AND EO 9397. PRINCIPAL PURPOSE: To record personal information on an individual whose duty performance requires entry to RRMC. ROUTINE USES: To coordinate with the appropriate official on an individual’s need to enter a restricted area. To record information on when and what type entry credential is issued to an individual. The SSN is used for further identification of an individual. DISCLOSURE: Mandatory.

Failure to disclose requested information would result in denied entry.

NAME (LAST, FIRST MIDDLE)

PART I – IDENTIFICATION

YES NO

ORGANIZATION/FIRM

SSN HEIGHT WEIGHT COUNTRY OF BIRTH CITIZENSHIP DOB SEX

PART II – SECURITY INFORMATION FOR UNESCORTED ACCESS

INVESTIGATION TYPE INVESTIGATING AGENCY INVESTIGATION COMPLETE (DAY, MONTH, YEAR) CLEARANCE

MY SIGNATURE BELOW CERTIFIES THE ABOVE SECURITY INFORMATION IS CORRECT

DATE NAME, GRADE OF ORGANIZATION SECURITY MANAGER PHONE NUMBER SIGNATURE

PART III – VISITOR / CONTRACTOR INFORMATION

EXPIRATION DATE DATE

COR / CONTRACT POC PHONE NUMBER SIGNATURE

PART IV - NATIONAL AGENCY CHECK

COMPLETED BY NAME DATE COMPLETED

FAVORABLE RESULTS

PART V - PERIMETER ACCESS ASSIGNED

PART VI – ENTRY APPROVAL

BY AUTHORITY VESTED IN ME, I AUTHORIZE ACCESS TO THE INDIVIDUAL IDENTIFIED IN PART I

DATE NAME, GRADE OF APPROVAL AUTHORITY SIGNATURE

CARD NUMBER

PART VII– ALT CAC CARD

EXPIRATION DATE

DATE NAME OF RRMC CARD ISSUING OFFICIAL SIGNATURE VERIFYING RECEIPT OF ALT CAC CARD

RRMC FORM 1407-R

ACCESS AREAS

CONTRACT NUMBER

YES NO

RMC-PFPA-RDRGP-SITE PERIM

SECURITY

BUILDING

RMC-PFPA-RDRGP-BDG-PERIM

ASSIGNED

ENTRANCE GATES

AUTHORIZED READER GROUP SIGNATURE

PFAC

RENEWAL?

SECRET CLEARANCE

NON ESCORT REQUIRED CARD

NO CLEARANCE

ESCORT REQUIRED CARD

GRANT ESCORT

PRIVLEDGE

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MARCH 2010
PART I – IDENTIFICATION
PART II – SECURITY INFORMATION
PART III – JUSTIFICATION AND CERTIFICATION
THE NEXT LINE MUST BE COMPLETED FOR ALL CONTRACTORS
SPONSORING RRMC ORG
RRMC COR/POC
PHONE NUMBER
EMAIL ADDRESS
MY SIGNATURE BELOW VERIFIES THAT I HAVE READ THE RRMC SECURITY AWARENESS TRAINING, THAT I UNDERSTAND THE RRMC OPSEC POLICY, AND MY ESCORT RESPONSIBILITIES.
DATE
PHONE NUMBER
APPLICANT SIGNATURE
PART IV – RESTRICTED/EXCLUSION AREA COORDINATION
PART V – ENTRY APPROVAL
Untitled
Untitled
Untitled
NAME LAST FIRST MIDDLE INITIAL:
ORGANIZATIONFIRM:
SSN:
HEIGHT:
WEIGHT:
DOB:
SEX:
INVESTIGATION TYPE:
INVESTIGATING AGENCY:
DATE INVESTIGATION COMPLETE DAY MONTH YEAR:
CLEARANCE:
NAME GRADE OF ORGANIZATION SECURITY MANAGER:
EXPIRATION DATE:
NAME GRADE OF APPROVAL AUTHORITY:
DATE:
CONTRACT NUMBER:
COR/CONTRACT POC:
DATE COMPLETED:
COMPLETED BY NAME:
CARD NUMBER:
CARD EXPIRATION DATE:
NAME OF RRMC CARD ISSUING OFFICIAL:
Check Box2: Off
Check Box7: Off
Check Box8: Off
Check Box11: Off
Check Box12: Off
Check Box13: Off
Check Box14: Off
Check Box4: Off
Check Box5: Off
Check Box15: Off
DATE 3:
DATE 2:
DATE 1:
PHONE NUMBER 1:
PHONE NUMBER 2:
Check Box3: Off
CITIZENSHIP:
COUNTRY OF BIRTH:

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