Attachment J7 - FORM FDA 3391.pdf
PDF 81 KB Posted
- Attached to
- Amendment 1 -Construction of Production Water Well at NCTR Federal contract opportunity
- Solicitation number
- FDA-SOL-1224382
About this file
This document contains an FDA security card access request form and information about a federal contract solicitation. The security card access request form collects individual applicant information such as name, contact details, physical attributes, and employment details for issuing FDA security card keys. The related federal contract solicitation is for the construction of a production water well at the National Center for Toxicological Research/Arkansas Regional Laboratory located in Jefferson, Arkansas. The solicitation seeks to install a new water well to support facility operations. The Department of Health and Human Services Food and Drug Administration Office of Acquisition and Grant Services is the contracting agency. The solicitation number is FDA-SOL-1224382 and it is identified as Amendment 1.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Amendment 1_rdw.pdf | ||
| FDA_SOL_75F40120R00024 .pdf | ||
| Attachment J6 - Past Performance Evaluation Questionnaire.pdf | ||
| Attachment J11 - COVID19 Visitor Questionnaire at JL.pdf | ||
| Attachment J10 - Statement of Work.pdf | ||
| Attachment J4 - Wage Detemination AR.pdf | ||
| Attachment J8 - FDA Form 3398.pdf | ||
| Attachment J9 - Certification of Current Arkansas State Contractors License.pdf | ||
| Attachment J2 - Drawings.pdf | ||
| Attachment J5 - Sample Client Letter.pdf | ||
| Attachment J1 - Project Manual.pdf | ||
| Attachment J3 - Cost Proposal Bid Schedule.pdf |
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Text version
CONTRACT EXPIRATION
SSN
FORM FDA 3391 (2/06)
CRED NUMBER
NEW
BUILDING
COMPANY NAME
DATE OF BIRTH
Male
Staff Fellow
FRONT
COMPLETE ONLY IF YOU ARE AN FDA CONTRACT EMPLOYEE
(See Privacy Act Statement on Reverse)
Female
OFFICE PHONE NUMBER
COLOR OF HAIR
U.S. CITIZENSEX
CENTER
Other (Explain) :
COLOR OF EYES
Inches
PHONE NUMBER (PROJECT OFFICER)
Intern
PLEASE TYPE OR PRINT INFORMATION
Visiting Scientist
FDA PROJECT OFFICER’S SIGNATURE
CONTRACT NUMBER
DATE
FDA SECURITY CARD
ACCESS REQUEST
FOR SECURITY OFFICE USE ONLY
EMPLOYEE ID NO.
CLASS
CHECK ONE:
Feet
Type of ID
SA CLASS
Lbs.
WEIGHT
No
Guest Worker
Yes
SECURITY REPRESENTATIVE’S SIGNATURE (Sponsor)
FellowshipStudent
ROOM NUMBER
Volunteer
Number on ID Type of ID Number on ID
YearMonth Day YearMonth Day
REGISTRAR SIGNATURE (Personnel Security) ISSUER SIGNATURE (Badging Office)
Special Government Employee
TERM OF APPOINTMENT
YearMonth Day YearMonth Day
EF
FULL NAME (Last, First, MI) OTHER NAMES USED (Maiden, Nickname, etc.)
REVISED
Department of Health and Human Services Food and Drug Administration
REISSUE
HEIGHT
VEHICLE TAG NUMBER
MAILING SYMBOL
STATE
LABORATORY PHONE NUMBER
PREVIOUS EDITIONS ARE OBSOLETE
YearMonth Day YearMonth Day
YearMonth Day YearMonth Day
ID NUMBER 1 ID NUMBER 2
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PRIVACY ACT STATEMENT
Authority
This information is provided pursuant to Public Law 93-597 (Privacy Act of 1974), December 31, 1974, for individuals applying for FDA Security Card Keys. Federal Property Management Regulations, 41 CFR 101.20.301, authorize the maintenance of systems by Government agencies for identifying individuals as employees in order to restrict access to Federal buildings after normal working hours and to areas not open to the general public.
Purposes and Uses
The principle purpose of the FDA Security Card Access Request, Form FDA 3391, is to maintain a record of all holders of the FDA Security Card Keys, for renewal and recovery purposes. This form is available only to personnel in the office issuing the Card Keys and the only information taken from it that may be given in response to inquiries is the office phone number, mailing symbol, and/or room number of the employee. Information may be disclosed to a congressional office at the request of the subject individual or to the Department of Justice in the case of litigation.
Effects of Nondisclosure
Failure to complete Form FDA 3391 will result in refusal to issue a Card Key.
Privacy Act Record Number 09-10-0018
FORM FDA 3391 (2/06) BACK
File details come from the government source that posted it. Updated .