Base Access Request_Rivanna Station.pdf

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Sources Sought Notice & Site Visit Invitation: NGIC Artifact Restoration and Conservation
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This document is a Base Access Request form required for visitors to access the Rivanna Station facility in support of a federal contract opportunity. The form collects personal identification information including name, date of birth, social security number, and race of the requestor, as well as the purpose of the visit, the government sponsor, and contract number. The information will be used to conduct vetting, identity verification, and a criminal background check per Army Regulation 190-13 and Department of Defense policy. Completed forms containing Controlled Unclassified Information must be encrypted and submitted to the Contracting Officer for approval. Access will be granted or denied based on the results of this process, and relevant personal information will be maintained on the installation access roster.

The related federal contract opportunity is a Sources Sought notice and site visit invitation for the National Ground Intelligence Center (NGIC) to identify qualified sources capable of restoring an NGIC-owned artifact. The notice and site visit are part of market research to support the government's requirements, which are detailed in the NGIC Artifact RC RFI and NGIC Artifact RC PWS DRAFT attachments. Interested parties should review all provided attachments to understand the full scope of the opportunity.

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NGIC Artifact RC PWS DRAFT.pdf PDF
NGIC Artifact RC RFI.pdf PDF
NGIC Artifact RC Picture Binder.pdf PDF

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Instructions

(1) The requester shall complete all elements in yellow. A completed form contains Personal Identifiable Information (PII); therefore, the requester must complete the CUI designation indicator (bottom right) as part of this process.

(2) The requester shall email the KO for a DoD SAFE "Drop-off" link to submit the form. NOTE: The contractor shall encrypt all messages containing PII. Please DO NOT encrypt the form itself, as the KO will not be able to open the file.

(3) The requester shall provide a separate email to the KO with the DoD SAFE message encryption password.

THIS SECTION TO BE COMPLETED BY COMPANY, ORGANIZATION,OR VISITING INDIVIDUAL. PLEASE REVIEW THE "INSTRUCTIONS' PRIOR TO COMPLETING THIS FORM.

5/8/2024 Through*

THIS SECTION TO BE COMPLETED BY GOVERNMENT SPONSOR

Full Last Name* Full First Name* Middle Name Gender* Date of Birth* SSN#*

White American Indian Black Hispanic Asian Pacific Islander White American Indian Black Hispanic Asian Pacific Islander

Controlled by:

Controlled by:

CUI Category: Sensitive Personally Identifiable Information (PII)

POC:

CUI

NGIC Artifact R&C Site Visit

DPTMS (RS) Form 21 Revised 05 Feb 2014

Army Regulation 190-13, "Army Physical Security Program", February 25,2011; Directive-Type Memorandum 09-012," Interim Policy Guidance for DoD Physical Access Control", March 19, 2013, Title 18, USC Section 1382

To facilitate vetting, identity proofing and verification of purpose for accessing the installation as required by DTM 09-012 and the check of National Crime Information Center (NCIC) Interstate Identification Index (III) records as required by AR 190-13.

Information will be processed through the National Crime Information Center (NCIC) Interstate Identification Index (III) database to determine criminal history (AW AR 190-13. Personal information for individuals who are authorized to access the installation as a result of this request will be maintained on the installation access roster for the duration of the authorized access period. Personal information for individuals who are denied access to the installation as a result of this request will be maintained on the installation access roster for approximately one year after the submission of the request.

Disclosure is voluntary; however, failure to provide the information may result in the inability to process an individual's request for unescorted access to U.S. Army Garrison, Fort Betvoir at Rivanna Station.

5/8/2024 Point of Contact Email Address*:

Point of Contact Telephone #*:

Dates of Access Request*:

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

Request for Unescorted Installation Access For use of this form, see Army Regulation 190-13, "Installation Access" and the "Instructions" page. The proponent agency is DPTMS.

PRIVACY ACT STATEMENT

DISCLOSURE:

CO or ORG*:

CO/ORG Point of Contact*:

Contract #:

Race* State License/ID, U.S.

Passport or Resident Allen #*

Purpose of Visit*:

Government Sponsor*:

Sponsor Organization*:

CAGE code:

Mike Dalton NGIC Artifact R&C Site Visit

434-951-1933

NGIC S-4

Government Sponsor*: Danielle Mitchell Sponsor Telephone #*: 434-980-7518 Sponsor Telephone #*:

CUI

CO or Org:
POC NAME:
POC Email:
POC Telephone:
#1 LAST Name:
#2 LAST Name:
#1 FIRST Name:
#2 FIRST Name:
#1 MIDDLE Name:
#2 MIDDLE Name:
Check Box1: Off
Check Box 2: Off
Check Box 3: Off
Check Box 4: Off
Check Box 5: Off
Check Box 6: Off
Check Box 7: Off
Check Box 8: Off
Check Box 9: Off
Check Box10: Off
Check Box11: Off
Check Box12: Off
SSN#2:
SSN#1:
ID #1:
ID #2:
Corporate Name:
Division or Office:
Name, Phone:
DOB#1_af_date:
DOB#2_af_date:
CAGE:
#1: [FEMALE]
#2: [FEMALE]

File details come from the government source that posted it. Updated .