Attachment 5 SFS Form 3_EAL Request.pdf

PDF 181 KB Posted

Attached to
OH ANG Rickenbacker AB SIPR Room Demolition and Renovation
Solicitation number
W50S8P23B0004
Issued by

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This document is a contractor and visitor request form requiring personal information such as name, social security number, driver's license details, company affiliation, and dates of access for individuals requiring entry to a controlled unclassified information site. It lists required sponsor details and security forces signatures for approval or denial.

The related federal contract opportunity is a solicitation from the Department of the Army National Guard to demolish and renovate a SIPR network room at Rickenbacker Air National Guard Base in Ohio. The solicitation number is W50S8P23B0004 and responses are due by the date listed on the Federal Business Opportunities website. The work includes demolition of the existing room and construction of a new secure facility meeting SIPR network standards.

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Attachment 1 Statment of Work Repair SIPR Room Bldg 875.pdf PDF
W50S8P-23-B-0004 Solicitation.pdf PDF
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CUI

121 SFS Form 3 (Nov 2021)

Controlled By:

CUI Category: PRVY Dissemination: FEDCON

POC:

CUI

EAL# 121 SFS CONTRACTOR/VISITOR REQUEST

CONTROLLED UNCLASSIFIED INFORMATION (CUI) This document contains information that must be protected under the Privacy ACT OF 1974 (See AFI 33-332) and protected from disclosure under the Freedom, of Information Act, 5 USC 552. Do not release outside of DoD channels without the consent of the originator’s office.

SSN: Mandatory for all unescorted entries. Escorts must be provided by the sponsoring organization for all personnel with missing information or the inability to validate the credentials.

DISCLOSURE IS VOLUNTARY; however, failure to disclose required information will prohibit unescorted access. Failure to provide complete and accurate information will delay the processing of this request.

EMPLOYEE/VISITOR INFORMATION BACKGROUND

CHECK

LAST FIRST MI SSN DRIVERS

LIC #

STATE COMPANY/ORG JOB

SITE

START

DATE

END

DATE

DATE METHOD

NOTES:

SPONSOR INFORMATION

NAME/RANK ORGANIZATION PHONE EMAIL DATE SIGNATURE

SECURITY FORCES USE ONLY

OFFICER NAME/RANK DATE SIGNATURE DENIED CONTRACTOR/ VISITOR

EAL:
EMPLOYEEVISITOR INFORMATION:
LASTRow1:
FIRSTRow1:
MIRow1:
SSNRow1:
DRIVERS LIC Row1:
STATERow1:
COMPANYORGRow1:
JOB SITERow1:
START DATERow1:
END DATERow1:
DATERow1:
METHODRow1:
LASTRow2:
FIRSTRow2:
MIRow2:
SSNRow2:
DRIVERS LIC Row2:
STATERow2:
COMPANYORGRow2:
JOB SITERow2:
START DATERow2:
END DATERow2:
DATERow2:
METHODRow2:
LASTRow3:
FIRSTRow3:
MIRow3:
SSNRow3:
DRIVERS LIC Row3:
STATERow3:
COMPANYORGRow3:
JOB SITERow3:
START DATERow3:
END DATERow3:
DATERow3:
METHODRow3:
LASTRow4:
FIRSTRow4:
MIRow4:
SSNRow4:
DRIVERS LIC Row4:
STATERow4:
COMPANYORGRow4:
JOB SITERow4:
START DATERow4:
END DATERow4:
DATERow4:
METHODRow4:
LASTRow5:
FIRSTRow5:
MIRow5:
SSNRow5:
DRIVERS LIC Row5:
STATERow5:
COMPANYORGRow5:
JOB SITERow5:
START DATERow5:
END DATERow5:
DATERow5:
METHODRow5:
LASTRow6:
FIRSTRow6:
MIRow6:
SSNRow6:
DRIVERS LIC Row6:
STATERow6:
COMPANYORGRow6:
JOB SITERow6:
START DATERow6:
END DATERow6:
DATERow6:
METHODRow6:
LASTRow7:
FIRSTRow7:
MIRow7:
SSNRow7:
DRIVERS LIC Row7:
STATERow7:
COMPANYORGRow7:
JOB SITERow7:
START DATERow7:
END DATERow7:
DATERow7:
METHODRow7:
LASTRow8:
FIRSTRow8:
MIRow8:
SSNRow8:
DRIVERS LIC Row8:
STATERow8:
COMPANYORGRow8:
JOB SITERow8:
START DATERow8:
END DATERow8:
DATERow8:
METHODRow8:
LASTRow9:
FIRSTRow9:
MIRow9:
SSNRow9:
DRIVERS LIC Row9:
STATERow9:
COMPANYORGRow9:
JOB SITERow9:
START DATERow9:
END DATERow9:
DATERow9:
METHODRow9:
LASTRow10:
FIRSTRow10:
MIRow10:
SSNRow10:
DRIVERS LIC Row10:
STATERow10:
COMPANYORGRow10:
JOB SITERow10:
START DATERow10:
END DATERow10:
DATERow10:
METHODRow10:
NOTES:
NAMERANKRow1:
ORGANIZATIONRow1:
PHONERow1:
EMAILRow1:
DATERow1_2:
SIGNATURERow1:
OFFICER NAMERANKRow1:
DATERow1_3:
SIGNATURERow1_2:
DENIED CONTRACTOR VISITORRow1:
Text1:
Text2:

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