Attachment 8 - Base Access Worksheet.pdf

Controlled Unclassified Information (CUI) (when filled in)

JOINT BASE CHARLESTON (JBCHS) BASE ACCESS WORKSHEET

AUTHORTIY: Section 3101, Title 44 United States Code, AFI 33-332, 5 USC 552A PURPOSE: The purpose for requesting personnel information is to assist security personnel in developing records to document contractor employee suitability for access to Joint Base Charleston (JBCHS) to work under Air Force contracts. The Social Security Number (SSN) and Date of Birth (DOB) are necessary to identify the person ofrecord. this information may be used to determine suitability of persons desiring access to JBCHS as well as for other lawful purposes including criminal background check and litigations.

INTENDED USE: All contractors and subcontractors working under Air Force contract requiring regular and frequent access to JBCHS in performance of their official duties.

Refer to JBCI 31-6, Contractor Access Control Program, for further guidance.

DISCLOSURE: Disclosure ofrequested information is voluntary. However, failure to provide information may result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the Air Force contract while serving in the capacity of prime contractor or subcontractor//supplier employee.

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Section I: Applicants Information

l. Name (Last, First, Middle) I I 2.008 I

3. Place of Birth I I 4. SSAN I

5. Current Address 5a. Street I I

5b. Apt# I 5c. City I I 5d. State I I 5e. Zip Code I

10. Driver's License or ID Card Number I 11 11 ·

Driver's License or ID Card State of issue I Section Il: Additional Information

l. Company Name I 112. Company Phone # I

3. Days Access Needed I I 4. Times Access Needed I

5. Start Date I I 6. End Date I

7. Description of work to be performed

8. Location work to be performed

9. US Citizen? D Yes □ No 110. Attach legible copy of State Drivers License or State ID card with clear photo

11. Have you ever been charged or convicted with a Felony?

12. Primary Contractor Email I

13. Applicants Signature I 1114. Date

Section m: Sponsor Information

l. Sponsor Name (Last, First, Middle) I 112. Sponsor Organization

3. Sponsor Phone# I 114. CAC DoD Control Number for DBlDS I

5. Sponsor Signature I I 16. Date

NOTE: INSTRUCTIONS FOR COMPLETING THIS WORKSHEET ARE ON THE REVERSE SIDE

JBCHARLSTON FORM 111 20220721

Pagel of2 Supersedes: All previous versions Prescribed by: JBCHARLESTONI 31-106

Controlled Unclassified Information (CUI) (When Filled In)

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JOINT BASE CHARLESTON (JBCHS) BASE ACCESS WORKSHEET (CONT.)

Section/

Number 1-11: Self-explanatory

Section II

Number 1-6: Self-explanatory

Number 7-9: Self Explanatory HOW LONG DOES IT TAKE You do not get the worksheet back once it has been turned into the SFS VCC. The worksheet may take up to 72-hours to process and sometimes longer if discrepancies are found.

Number 10: Must attach a copy of Drivers License or State ID with a clear Photo. Failure to provide this and your application will not be processed.

Number 11: When answering the FELONY question be honest! If the NCIC investigation produces a positive finding and you answered "NO", your access to JB CHS will be denied. Any individual convicted of a felony to include but not limited to: murder, assault w/intent to commit murder, rape, extortion, robbery, armed robbery, any drug offense and other Felony offenses will be denied access to JB CHS. In addition, any individual currently on parole, probation, have an active warrant or on the Sex Offender Registry will be automatically denied access to the installation.(Employee MUST initial/No One Else) I I Number 12-14: Self-explanatory

Section III:

Number 1-6: Self-explanatory

CONTRACTOR PASS PROCEDURES

(a) Once the contracting company hires the individual, they will be required to fill out all information on the front of this worksheet, so they can obtain a badge/pass. It is the responsibility of the company requesting the contractor badge/pass to verify the validity of the employee's driver license and legal status prior to the request being submitted. Any individual operating a vehicle on the installation must insure that it meets the minimum insurance requirements, have a valid Driver's License and Vehicle Registration in the vehicle. The issuance of a badge/pass is a privilege that can be withdrawn and the individual can be barred from base for noncompliance with Joint Base Charleston policies and or USAF Directives. This badge/pass must be in possession of the contractor at all times while on the installation. Contractor badge/pass must be visible on the employee at all times.

(b )When reporting to the Visitor Control Center to obtain an identification badge/pass, each employee will present a valid driver's license or state issued picture identification.

Drivers License that say "Not For Federal Use" , Nor For Federal Purpose" or "Not For Federal Identification" will NOT be accepted.

(c)The badge/pass does not allow family members or friends to be sponsored on the installation at any time. In cases when family or friends must drive the contractor to the base, the drop off point is at the base entry gates. Employees are responsible for their own transportation to the job site.

( d)If a contractor is terminated or upon completion of the job or the expiration of the identification card/pass, the prime contractor shall ensure that all base identification cards/ passes issued to employees and subcontractor employees are returned to the issuing office. Either Security Forces Visitor Control Center on Air Base, Bldg. #1953, or Security Forces Visitor Control Center on Weapon Station, Bldg. #3

JBCHARLSTON FORM I 11 20220721

Page 2 of2 Supersedes: All previous versions Prescribed by: JBCHARLESTONI 31-106

Controlled Unclassified Information (CUI) (When Filled In)

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