Blank Affidavit.pdf

ROBINS AIR FORCE BASE GEORGIA ACCESS AFFIDAVIT

BACKGROUND CHECK RELEASE FORM

ALL SIGNATURE BLOCKS MUST BE SIGNED Page 1 of 2

EMPLOYEE/CONTRACTOR/SUBCONTRACTOR ACCESS AFFIDAVIT

(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)

Submit one copy to 78 SFS. Original to Employee. This data will be used to screen individuals who have or are seeking access to US Air Force installations or facilities controlled by the Air Force. Please answer each question. Access will be denied if this questionnaire is incomplete or missing from the Contractor Access Packet. This information will be used to generate state and federal criminal history checks

CHECK APPLICABLE BOX:

CONTRACTOR SUBCONTRACTOR NAF EMPLOYEE CDC EMPLOYEE

EXTENDED STAY WITH ACTIVE DUTY MEMBER DISTINGUISHED VISITOR

FEDERAL AGENT LOCAL OFFICER STATE EMPLOYEE

1. NAME (Last, First, Middle) 2. SEX 3. SSAN 4. DATE OF BIRTH 5. RACE

6. SCARS/MARKS/TATTOOS 7. HAIR COLOR 8. EYE COLOR 9. HEIGHT 10. WEIGHT

11. ALIAS 12. DRIVER LICENSE # 13. STATE

14. CURRENT RESIDENCE

ADDRESS:

PHONE NUMBER:

15. CITY 16. STATE 17. ZIP CODE 18. COUNTRY

PLACE OF BIRTH

19. CITY 20. STATE (If Applicable) 21. COUNTRY

22. CITIZENSHIP (COUNTRY) 23. RESIDENT ALIEN # OR IMMIGRATION DOCUMENT # and DESCRIPTION

PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING VISITOR INITIALS:

YES NO

Have you ever been barred from entry/access to any military installation or facility?

Have you been issued a summons, citation or ticket to appear in court in a criminal proceeding against you; are you on trial or awaiting a trial on criminal charges; or are you currently awaiting sentencing for a criminal offense?

Have you ever received deferred adjudication from any court?

Have you ever been charged with any felony offense?

Have you ever been convicted of any felony offense?

Have you ever been arrested by any police officer, sheriff, marshal or any other type of law enforcement officer?

Have you ever been jailed or imprisoned for any length of time? (Minutes, Hours, Days, Months, Years)

Have you ever been charged with a firearms or explosives offense?

Have you ever been charged of espionage, sabotage, treason, murder, sexual assault, armed assault or robbery, rape, child molestation, felony drug possession with intent to sell or drug distribution?

Do you have any open warrants? (reason, county)

If you answered “Yes” to any question above, explain in detail below. You may attach a separate page if necessary. You are required to answer each question(s) fully and truthfully. Your failure to comply could be grounds for base access denial.

The information herein is For Official Use Only (FOUO) which must be protected under the Freedom of Information Act of 1966 and Privacy Act of 1974, as amended. Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in criminal and/or civil penalties.

Background Check Release Form as of 21 November 2014

CHAPEL EMPLOYEE/VOLUNTEER

GUEST OF _______________________

OTHER

NOTE TO APPLICANT: ATTESTATION

I attest that I have been briefed by my employer/sponsor, and understand the purpose of the background check. I understand the information on this form is being collected in accordance with 50 U.S.C., Section 797 and DoDD

5200.8 permitting the installation commander to limit access to the installation for security reasons and that the information provided will be used to screen personnel who are seeking access to U.S. Air Force installations. I have voluntarily completed this form and shall provide the U.S. Air Force a copy of my fingerprints when requested. I understand that by signing the application I acknowledge that I have been made aware of, and have reviewed the list of Robins AFB “Disqualifying Factors” above. I hereby give consent and authorization for the Air Force to conduct any additional background screenings deemed necessary over the next 12 months, unless otherwise directed by 78 SFS, to include comparing/checking my fingerprints against local, state and federal criminal databases. The information I have provided on this application is true, complete and correct to the best of my knowledge and is provided in good faith. I understand that knowingly and willfully making false statements can be punished by fine, imprisonment, or both (18 U.S.C Section 1001).

Applicant Signature________________________________________Date:_____________________ Company Name:______________________________________________________________________ Sponsor/Badging Agent : ____________________________________ Title: _____________________ Name of Squadron: ___________________________________ Phone Number : __________________ Building # or location of employment _____________________________________________________ Expiration Date of Badge/Pass and Access Time Frame: _______________________________________

Privacy Act Statement AUTHORITY: Section 3101 Title 44, United States Code, 5 USC 552A, AFI 33-332

PRINCIPAL PURPOSE(S): The purpose for requesting personal information is to assist police personnel in documenting contractor employee suitability for access to USAF installations. The Social Security number (SSAN) and Date of Birth (DOB) are necessary to identify the person and records. This information may be used to determine suitability of person desiring access to the installation as well as for lawful purposes including law enforcement and litigation.

INTENDED USE: For all contractors and subcontractors who require regular and frequent access to the installation in performance of their official duties.

To allow base access to government and federal agency employees and their family members. Patrons described in AFI 34-101, Table A2.2. are authorized limited use of military Services MWR activities at the discretion of the installation commander provided adequate facilities are available and activities are currently underutilized by higher priority users. Robins Services MWR activities are underutilized.

DISCLOSURE: Disclosure of requested information is mandatory. Failure to provide information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the Air Force contract while serving in the capacity of prime contractor or subcontractor/supplier employee.

AGENCY DISCLOSURE

The public reporting burden for this collection of information is estimated to take 3 to 30 days per response, including the timeframe for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information.

Sponsor/Badging Agent Digital Signature:

78 SFS USE ONLY Approve/Disapprove Reason:

ALL SIGNATURE BLOCKS MUST BE SIGNED PAGE 2 OF 2

The information herein is For Official Use Only (FOUO) which must be protected under the Freedom of Information Act of 1966 and Privacy Act of 1974, as amended. Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in criminal and/or civil penalties.

Background Check Release Form as of 21 November 2014

ROBINS AIR FORCE BASE GEORGIA ACCESS AFFIDAVIT BACKGROUND CHECK RELEASE FORM