Attachment 5_SIOAN Form 380-2 Personnel Data Questionnaire.pdf
PDF 91 KB Posted
- Attached to
- IWTP SUPPORT Federal contract opportunity
- Solicitation number
- W911KF22Q0040
About this file
This document is a personnel data questionnaire form used to collect biographical information from individuals requiring access to Anniston Army Depot. The form requests information such as name, Social Security number, date and place of birth, citizenship status, physical description, driver's license and address history. It will be provided to the Directorate of Emergency Services and officials within the Department of Defense who require the information to perform official duties. Disclosure is voluntary but necessary to obtain unescorted installation access. The individual acknowledges the form's use and that false statements can be punished by law. Approval or denial of access will be indicated upon review by installation officials.
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| W911KF-22-Q-0040 AMEND 01.pdf | ||
| Attachment 3_Past_Performance_Questionnaire.pdf | ||
| Attachment 4_Evidence of Authority to Sign Offers.pdf | ||
| Attachment 2_Wage Determination No 2015-4587.pdf | ||
| ATTACHMENT 1_SOW - IWTP Spt (corrected copy).pdf | ||
| W911KF-22-Q-0040.pdf |
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Text version
Request Recurring: Yes / No
PERSONAL DATA QUESTIONNAIRE – (See AR 380-67 for use of this form; proponent is AMSTA-AN-ESP)
CONTRACTOR COMPANY NAME (Prime)
WORK PHONE
SUBCONTRACTOR NAME CONTRACT NUMBER CONTRACT EXPIRES
INDIVIDUAL’S NAME (First name, Middle name, Last name) ***NO INITIALS *** SSN
OTHER NAMES USED (INCLUDE FORMER MARRIED NAMES) TYPE BADGE/AREA:
DATE OF BIRTH PLACE OF BIRTH CITIZENSHIP
MONTH
DAY
YEAR CITY COUNTY
STATE
*** NOTE ***IF YOU WERE BORN OUTSIDE OF THE UNITED STATES, YOU MUST FURNISH PROOF OF U.S.
CITIZENSHIP UPON SUBMISSION OF THIS FORM TO THIS INSTALLATION. PROOF OF U.S. CITIZENSHIP MUST BE SUBMITTED IN PERSON BY THE INDIVIDUAL, ALONG WITH THIS FORM, TO THE BADGE OFFICE, PHYSICAL SECURITY DIVISION, DES.
PHYSICAL DESCRIPTION COLOR EYES COLOR HAIR HEIGHT WEIGHT SEX
RACE
DRIVERS LICENSE NO.
STATE OF ISSUE OR STATE IDENTIFICATION NO. STATE OF ISSUE
ADDRESSES FOR THE PAST FIVE (5) YEARS, INCLUDING PRESENT ADDRESS: (STREET, CITY, COUNTY, STATE)
1. 4.
(County) (County)
2. 5.
(County) (County)
3. 6.
(County) (County)
AUTHORITY: Internal Security Act of 1950 (50 USC 797); Executive Order 9397. PRINCIPAL PURPOSE: To document information necessary for selection, assignment or termination for persons desiring entry to all, or parts, of Anniston Army Depot.
ROUTINE USES: The information provided will be furnished to the Directorate of Emergency Services at Anniston Army Depot; to officials within the Department of Defense who have a need for it to perform official business. NATURE OF DISCLOSURE:
Disclosure of the requested information is voluntary. Failure to provide the information, however, may result in being denied unescorted access to the installation.
LEGAL SIGNATURE OF INDIVIDUAL REQUESTING ACCESS: DATE
********************** CERTIFICATION **********************
I certify that the individual named above is, in fact, an employee of the company as listed above. I understand that a knowing and willful false statement can be punished by fine or imprisonment, or both. (U.S. Code, title 18 USC 1001)
SIGNATURE OF AUTHORIZED PERSONNEL/REPRESENTATIVE DATE
DO NOT WRITE BELOW THIS LINE
DISAPPROVED SIGNATURE OF DISAPPROVING OFFICIAL DATE
APPROVED
____ PHOTOGRAPHIC BADGE
____ NON-PHOTOGRAPHIC BADGE – NO ESCORT REQUIRED
____ NON-PHOTOGRAPHIC BADGE - ESCORT REQUIRED
NO DRIVING PRIVILEGES
Badge Office Issues Letter
SIGNATURE OF APPROVING OFFICIAL: DATE
SIOAN Form 380-2, Rev 11 Mar 08 PREVIOUS EDITIONS OBSOLETE
File details come from the government source that posted it. Updated .