Attachment 5_SIOAN Form 380-2 Personnel Data Questionnaire.pdf
PDF 91 KB Posted
- Attached to
- LAB SAMPLING AND ANALYSIS Federal contract opportunity
- Solicitation number
- W911KF-22-Q-0043
About this file
This document contains a Personnel Data Questionnaire form and information about a related federal contract opportunity for laboratory sampling and analysis services.
The Personnel Data Questionnaire is a form used by Anniston Army Depot (ANAD) to collect personal information for security badge requests and installation access. It solicits an individual's name, date of birth, physical description, citizenship status, addresses for the last five years, and certification by an authorized company representative. The related federal contract opportunity is a solicitation issued by the Department of the Army Materiel Command Contracting Command Detroit Arsenal. It seeks analytical laboratory services to comply with ANAD's environmental monitoring and testing requirements under its NPDES permit and to support characterization of various materials and substances for ANAD's environmental and quality programs. Services include testing wastewater, stormwater, and hazardous waste samples in accordance with all applicable state and federal regulations.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Amendment 01.pdf | ||
| W911KF-22-Q-0043-RELEASED.pdf | ||
| Attachment 2_Wage Determination No 2015-4587.pdf | ||
| Attachment 1 FY23 Lab Sampling - SOW.pdf | ||
| Attachment 3_Past_Performance_Questionnaire.pdf | ||
| Attachment 4_Evidence of Authority to Sign Offers.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 .