Background Consent Form.docx
DOCX document 101 KB Posted
- Attached to
- Clean Diesel Fuel Tank
- Solicitation number
- FA480125Q0013
About this file
The provided file is a Background Consent Form for accessing Holloman Air Force Base, requiring individuals to authorize a background check to determine base entry eligibility. The form captures personal information including legal name, Social Security Number, birth date, citizenship status, and signature, with explicit warnings about confidentiality under the Privacy Act of 1974.
The related federal contract opportunity (Solicitation Number: FA480125Q0013) is for a one-time diesel fuel tank cleaning service at Holloman Air Force Base. The requirement involves cleaning a 10,000-gallon diesel fuel tank, with the contractor responsible for providing all necessary labor, materials, tools, and equipment. A mandatory site visit is scheduled for 30 April 2025 at 1000, meeting at the visitor center, and potential vendors must submit questions and answers by 1 May 2025 at 1400 to the listed points of contact. The solicitation is issued by the Department of the Air Force Air Combat Command.
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Text version
BACKGROUND CHECK
CONSENT FORM
I, __________________________________________________, (Name – typed/printed) Hereby authorize the U.S. Government (United States Air Force) to conduct background checks confirming my eligibility or ineligibility to gain access to Holloman Air Force Base, New Mexico.
Examples of conditions that may identify ineligibility to access the installation include, but are not limited to, substantiated misconduct, conviction or arrests for violent behavior, dishonesty, sexually aberrant behavior, warrants for arrest, open investigations, or felony charges.
I do so with full knowledge that this information is confidential and as such protected from unauthorized disclosure by the Privacy Act of 1974, as amended.
It is also my understanding that any information provided shall be treated confidentially and be used solely to determine whether I am eligible to access the installation.
***PRIVACY ACT INFORMATION***
PRINT LEGAL NAME:
| SSN: |
| BIRTH DATE: |
SIGNATURE:
US CITIZEN? (Circle One): YES / NO
DATE:
PRIVACY ACT STATEMENT
IAW the Privacy Act of 1974, the contents of this document contain privileged or other confidential information. Unauthorized disclosure may result in civil and criminal sanctions. If you are not the intended recipient, or believe you may have received this communication in error, do not reproduce, retransmit, disseminate, or otherwise use this information.
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File details come from the government source that posted it. Updated .