Attachment 5 - KPM 180 Visiting Contractor Request.pdf

PDF 236 KB Posted Apr 5, 2021

Attached to: Kaena Point Satellite Tracking Station (KPSTS) Booster Pump Install
Solicitation number: FA521521R0013
Issued by: Department of the Air Force Pacific Air Forces

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Other files

File	Type	Posted
As Builts and IOMs Booster Pump 2 Bldg 30.pdf	PDF	Apr 16, 2021
Attachment 4 - NDAA Section 889 Certification.pdf	PDF	Apr 5, 2021
Attachment 1 - Statement of Work dated 25 Aug 2020.pdf	PDF	Apr 5, 2021
Solicitation - FA521521R0013.pdf	PDF	Apr 5, 2021
Attachment 3 - AF 3064 Progress Schedule.xlsx	XLSX spreadsheet	Apr 5, 2021
Attachment 2 - Wage Determination HI20210001.pdf	PDF	Apr 5, 2021

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KA’ENA POINT SATELLITE TRACKING STATION (KPSTS)

APPLICATION FOR PERSONNEL TO OBTAIN ID CARD/BASE ACCESS PASS REGISTRATION MEMORANDUM

Privacy Act Statement AUTHORITY: Section 3101, 10 U.S.C. 5013, Title 44, US Code, 5 USC 552A, AFMAN 31-113, , 10 U.S.C. 5041; OPNAVINST 5530.14 E, Navy Physical Security; Marine Corps Order 5530.14A, Marine Corps Physical Security Program Manual; and E.O.9397 (SSN), and impending directives as amended.

PRINCIPAL PURPOSES: The purpose of requesting personal information is to assist security personnel in developing records to document all personnel, contractor, military, state, Government and other mission partner’s employee’s suitability for access to Kaena Point Satellite Tracking Station, Hawaii. The social security number and date and place of birth are necessary to identify persons, maintaining records, and for criminal history/background checks.

ROUTINE USES: This information may be used to determine suitability of persons desiring access to Kaena Point Satellite Tracking Station, Hawaii as well as for other lawful purposes including law enforcement and litigation.

DISCLOSURE: Voluntary, Not providing the requested information and SSN may cause this memorandum to not be processed or to positively identify the person(s) requesting access, which may result in privileges being refused or withdrawn.

SORNs: F031 AF SF B, F031 AF SP O, 62 FR 31793, F031 AF SP M, 62 FR 52695, F031 AFMC C, 75 FR 39500, F031 AF SF F, 74 FR 39674, F036 AF PC Q, 62 FR 31793, NM05512ꞏ2, 79 FR 19593 and impending directives as amended.

The Privacy Act Statement will apply throughout the duration of the contract while serving in the capacity of prime contractor or subcontractor/supplier/employee.

(INSTRUCTIONS)

1. All information must be typed; Last Name, First Name, MI, SSN, Citizenship.

2. The only information that can be written is date and signatures at the bottom; original signatures are required at time of application.

3. Must show current vehicle registration, safety inspection, certificate of automobile insurance, and driver’s license and/or other form of picture identification for vehicle(s) and driver(s) upon arrival.

4. Any individual with a security clearance will be denied access and required to submit a JPAS visit request. Any individual with a security clearance will be denied access and required to submit a JPAS visit request.

5. This letter must be received by the Security Office NLT 14 days prior to issuing badges. Approved letters are only valid for 30 days and a new one must be submitted.

6. Place of performance/location visiting must be properly annotated. I.E: Kaena Point Bldg. 10, Power Plant, etc., Base-wide access requires justification and approval from installation commander and must be submitted/approved prior to arrival.

7. Project Inclusion date must be entered. Expiration date WILL NOT exceed the length of the current physical visit, 30 days or contract, whichever is less.

8. Incomplete memorandums or memorandums with errors will be returned for correction; they will not be processed. Submission of this letter does not guarantee approval of entry, contract leads are encouraged to follow-up prior to arrival, for any personnel who may not have been authorized.

9. This memorandum will be sent via encrypted e-mailed to a Government e-mail address unless otherwise specified on this memorandum.

CONTROL NUMBER: (Assigned from KPSTS) FROM: (Organization & Address)

CONTRACT NUMBER AND EXPIRATION

DATE

(N62478-##-D-####, T.O. #### MM/DD/YY)

PROJECT INCLUSION DATES

(NOT exceed the length of the current physical visit, 30 days, or contract, whichever is less.) (Example: 1-13 Apr)

DAYS/HOURS /VISITING

(Example: Mon-Fri / 0700-1700)

Weekends & Holidays are Not Authorized

PLACE OF

PERFORMANCE

(Example: Bldg. 10, Power Plant, etc.)

JUSTIFICATION: ((Ex :) Subcontractor Paradise Concrete need to access on site to repave parking lot. (BE SPECIFIC!).

Prime Contractor & POC: (is A. A. Gardena, Inc. ACO (Contracting Officer) is Jane Smith.)

PERSONNEL/VISITOR LISTING

Last Name:

(Ex :) Smith

First Name:

John

MI:

DOB:

Date of Birth

Place of Birth:

Winville, MD

Driver’s License # or State ID #

Citizenship SSN#

50 SFS

Approved?

PREVIOUS EDITIONS ARE OBSOLETE PRIVACY ACT INFORMATION: The information in this memorandum is FOR OFFICAL USE ONLY. Protect IAW the Privacy Act of 1974

A mirrored PRAK Production

Kaena Point Memo 180, V2 1 July 2019

Last Name:

(Ex :) Smith

First Name:

John

MI:

DOB:

Date of Birth

Place of Birth:

Winville, MD

Driver’s License # or State ID #

Citizenship SSN#

50 SFS

Approved?

THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A FALSE, FICTICIOUS OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED STATES

CODE, SECTION 1001.

REQUESTOR NAME: Date:

Phone: REQUESTOR E-mail:

Sponsor’s Email:

Date: Sponsor’s Name:

Phone:

ALL PERSONNEL LISTED ON THIS ENTRY AUTHORITY LIST (EAL) WITH APPROVAL, HAVE BEEN CLEARED, AND VETTED FOR ENTRY TO KAENA POINT SATELLITE TRACKING STATION (KPSTS) ALL VISITORS HAVE MET THE REQUIREMENT FOR UNESCORTED ENTRY, HAD A TIER-1 INVESTIGATION (FORMALLY NACI), BEEN VETTED IN ACCORDANCE WITH AIR FORCE MANUAL 31-113, INSTALLATION PERIMETER ACCESS CONTROL, AND DIRECTIVE-TYPE MEMORANDOM 09-012, INTERIM POLICY GUIDANCE FOR DoD PHYSICAL ACCESS CONTROL.

Sign 50 SFS Approver’s

Date: Print Approver’s Name:

Phone:

E-mail:

PREVIOUS EDITIONS ARE OBSOLETE PRIVACY ACT INFORMATION: The information in this memorandum is FOR OFFICAL USE ONLY. Protect IAW the Privacy Act of 1974A mirrored PRAK Production

Kaena Point Memo 180, V2 1 July 2019

CONRTOL NUMBER Assigned from KPSTS:

FROM Organization Address:

CONTRACT NUMBER AND EXPIRATION DATE N62478D TO MMDDYY:

PROJECT INCLUSION DATES NOT exceed the length of the current physical visit 30 days or contract whichever is less Example 113 Apr:

DAYSHOURS WORKEDVISITING Example MonFri 06301700:

PLACE OF PERFORMANCE Example Bldg 10 Power Plant etc:

JUSTIFICATION Ex Subcontractor Paradise Concrete need to access on site to repave parking lot BE SPECIFIC:

Prime Contractor POC is A A Gardena Inc ACO Contracting Officer is Jane Smith:

Last Name Ex SmithRow1:

First Name JohnRow1:

MI ARow1:

DOB Date of BirthRow1:

Place of Birth Winville MDRow1:

Drivers License or State ID Row1:

CitizenshipRow1:

SSNRow1:

Last Name Ex SmithRow2:

First Name JohnRow2:

MI ARow2:

DOB Date of BirthRow2:

Place of Birth Winville MDRow2:

Drivers License or State ID Row2:

CitizenshipRow2:

SSNRow2:

Last Name Ex SmithRow3:

First Name JohnRow3:

MI ARow3:

DOB Date of BirthRow3:

Place of Birth Winville MDRow3:

Drivers License or State ID Row3:

CitizenshipRow3:

SSNRow3:

Last Name Ex SmithRow4:

First Name JohnRow4:

MI ARow4:

DOB Date of BirthRow4:

Place of Birth Winville MDRow4:

Drivers License or State ID Row4:

CitizenshipRow4:

SSNRow4:

Last Name Ex SmithRow5:

First Name JohnRow5:

MI ARow5:

DOB Date of BirthRow5:

Place of Birth Winville MDRow5:

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CitizenshipRow5:

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First Name JohnRow6:

MI ARow6:

DOB Date of BirthRow6:

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Last Name Ex SmithRow3_2:

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First Name JohnRow11:

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Drivers License or State ID Row11:

CitizenshipRow11:

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Last Name Ex SmithRow12:

First Name JohnRow12:

MI ARow12:

DOB Date of BirthRow12:

Place of Birth Winville MDRow12:

Drivers License or State ID Row12:

CitizenshipRow12:

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Last Name Ex SmithRow13:

First Name JohnRow13:

MI ARow13:

DOB Date of BirthRow13:

Place of Birth Winville MDRow13:

Drivers License or State ID Row13:

CitizenshipRow13:

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Last Name Ex SmithRow14:

First Name JohnRow14:

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DOB Date of BirthRow14:

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Last Name Ex SmithRow15:

First Name JohnRow15:

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DOB Date of BirthRow15:

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Last Name Ex SmithRow16:

First Name JohnRow16:

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DOB Date of BirthRow16:

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First Name JohnRow17:

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DOB Date of BirthRow17:

Place of Birth Winville MDRow17:

Drivers License or State ID Row17:

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REQUESTER NAME:

Date:

Sign Sponsors Name:

Sign 50 SFS Approvers Name:

Date_3:

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File details come from the government source that posted it. Updated Apr 5, 2021.