ATTACHMENT JL-4_BASE ACCESS FORMS.pdf

Solicitation No.

N40192-21-R-9100

INTEGRATED SOLID WASTE MANAGEMENT AND

PAVEMENT CLEARANCE SERVICES (ISWM)

AT ALL U.S. NAVAL BASE GUAM ACTIVITIES AND

TENANTS, INDUSTRIAL AND U.S. NAVAL

HOSPITAL FACILITIES (MEDICAL TREATMENT

FACILITIES) ON GUAM, OTHER U.S. MILITARY

ACTIVITIES OR DOD/FEDERAL AGENCIES AT

VARIOUS ACTIVITIES/LOCATIONS, GUAM.

ATTACHMENT JL-4

NAVAL BASE ACCESS REQUEST FORMS

Date:

To: Ms. Elizabeth E. Balajadia, Naval Base Guam (NBG) Visitor Control Center Supervisor From:

Subj: BASE ACCESS REQUEST -

CONTRACT INFORMATION:

Contract No./ Title:

Contract Start & Expiration Date:

Prime Contractor Name:

Prime Contractor Address:

Contractor Coordinator:

(Name, Title & Phone Number)

Project Location(s) on Naval Base Guam Installation:

(Check mark all that apply)

Main Base Apra View Housing Apra Palms Housing NAVMAG Polaris Point Turner Housing Flag Circle JRM Naval Hospital

NCTS

Required Access Dates:

(Applies only when dates differ from the contract dates stated above.) From: To:

Required Access Days & Times:

EMPLOYEE INFORMATION:

On company letterhead, attach list all employee(s), requiring base access under this contract. List your sub-contractor employees separately. See attached page for format guidance.

SPONSOR INFORMATION:

Name & Title:

Command:

Phone No:

Email Address:

The above listed Prime Contractor is authorized to operate on-board Naval Base Guam Installation. The above listed Prime Contractor Coordinator will provide and liaison directly with NBG Visitor Control Center, all required contractor employee information, to include sub-contractor employee information, for the purpose of securing authorized base access credentials.

Government Sponsor Signature:

Other (Specify):___________________________

(e.g. MON-FRI/0600-1800)

CONTRACTOR COMPANY LETTERHEAD

DATE:

CONTRACT NUMBER & TITLE:

Name & Address of Sub-Contractor: (If applicable)

Full Legal Name (Last, First, MI)

NCAC Holder

CERTIFICATION:

"I hereby certify that all personnel listed above are either born U.S. citizens, naturalized U.S. citizens with the naturalization number shown, or legal aliens with the alien registration number indicated and declare under penalty and perjury that all of the information provided on this form is true, complete and correct”.

Contractor POC Printed Name & Title Date

GOVERNMENT SPONSOR ACKNOWLEDGEMENT

Printed Name & Title Date