Background Release Worksheet.pdf
PDF 452 KB Posted
- Attached to
- Security Lighting Upgrade
- Solicitation number
- W50S7W24B0001
- Issued by
-
Department of the Army National Guard
About this file
The document provided is a Background Release Worksheet for the 122nd Security Forces Squadron related to a federal contract opportunity.
The worksheet contains information required for conducting background investigations on individuals seeking access to the contract site, including their personal details, driver's license information, and citizenship/immigration status. It also includes contract-specific details such as the start and end dates, point of contact, and contractor/subcontractor information. The worksheet requires the individual's signature to authorize the release of this information for the background check.
The related federal contract opportunity is for a Security Lighting Upgrade project at Fort Wayne, IN with a period of performance of 30 calendar days. It is a small business set-aside with a size standard of $19M and NAICS code 238210. The project magnitude is between $100,000 and $250,000, and a pre-bid conference is scheduled for September 4, 2024. The award will be made to the responsible bidder with the most advantageous bid considering only price and price-related factors. A bid bond is required with the offer.
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Text version
122d Security Forces Squadron Background Check Release Worksheet
This worksheet may contain information which must be protected IAW AFI 33-332 and DoD 5400.11; Privacy Act of 1974 as amended 5 U.S.C. 552a applies, and is FOR OFFICIAL USE ONLY(FOUO).
RECIPIENT IS RESPONSIBLE FOR SAFEGUARDING AND MAINTAINING THIS PRODUCT IAW PRIVACY ACT OF 1974 PL 93-579.
The following information is required by law enforcement agencies and other entities for identification purposes when checking records.
It is confidential and will not be used for any other purpose.
ALL PORTIONS AND SECTIONS ARE MANDATORY
CONTRACT DATES FOR GATE ACCESS
(To be completed by Base Contracting/POC)
END DATE: Project Name, Building, and/or Location: START DATE:
Point of Contact: Phone Numbers: Office Cell
CONTRACTOR DETAILS
(To be completed by Primary Contractor)
Primary Contractor: Sub Contractor: Sub-Sub Contractor:
Escort: Escort Phone Number:
INDIVIDUAL ACCESS INFORMATION
Full Legal Name: Date of Birth:
Circle One Circle One Gender: MALE FEMALE Race: Asian Black Hispanic Native Other White
Driver’s License Number: Issuing State: Citizenship/Immigration Status:
Home Address: City: State:
INDIVIDUAL INFORMATION RELEASE
(Must be signed to authorize for access)
In connection with my application to provide contract services, I understand that background investigation checks are to be made on me including, criminal convictions, motor vehicles, and other reports. Further, I understand that the 122d Security Forces Squadron will be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my driving, criminal, and or civil claims.
I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so. This authorization and consent shall be valid in original or electronic form.
Applicant Wet Signature Only
For Security Forces Use Only
Unfavorable III Favorable BMV Unfavorable BMV Favorable III
Date Checked: Initials:
| Point of Contact: |
| Phone Numbers Office: |
| Cell: |
| Primary Contractor: |
| Sub Contractor: |
| SubSub Contractor: |
| Escort: |
| Escort Phone Number: |
| Drivers License Number: |
| Home Address: |
| City: |
| Text4: |
| Text5: |
| Text6: |
| Text7: |
| Text8: |
| Text9: |
| Start Date: |
| End Date: |
| Text3: |
| Text10: |
| Initials: |
File details come from the government source that posted it. Updated .