CONTRACTOR EAL FORM.pdf

ALPENA COMBAT READINESS TRAINING CENTER

MICHIGAN AIR NATIONAL GUARD

SECURITY FORCES

CONTRACTOR ACCESS ENTRY REQUEST

Authority: 10 U.S.C. 8013 and Privacy Act of 1974 Principle Purpose: To establish an entry control access list for personnel needing unescorted access to the installation for the Security Forces Primary Use: For contractors and vendors submitting personnel for background checks for unescorted access to the installation for the purpose of conducting business with the installation.

Disclosure: Information requested is voluntary. Failure to provide any of the requested information will result in access to the installation being denied.

Instructions: This form will be completed by contractors/vendors requesting access for personnel needing unescorted privileges to the installation for the purpose of completing a contract for the installation. Once this form is completed and certified by security forces personnel it will be posted at the installation main gate and a copy issued to the installation sponsor and maintained at the security forces administration building. This form should be submitted to the Security Forces Pass and ID section NLT 10 duty days prior to the start of the contract to allow for appropriate background and administrative actions to occur. Failure to do so can prevent or delay access. Once completed, this form should be emailed to: leroy.r.krentz.ctr@mail.mil &/or loretta.l.smith9.ctr@mail.mil. NOTE: If the form is not completely filled out correctly it will be returned. If personnel are determined to not have proper clearance to access the installation, this form will be returned to the requestor and updated. It will not be considered valid until certified by appropriate security forces personnel.

SECTION 1:

CONTRACTOR INFORMATION AND REQUEST

Company/Vendor: Company Telephone #:

Contract for/or type of service: Contract Number:

Check on of the following: Prime on the contract: Subcontractor: Vendor:

If Sub-contractor, name of the primary: Job Site Telephone #:

Company Address: Start Date of Contract: End Date:

Job Site:

PERSONNEL ROSTER

First name listed needs to be the local project manager, site supervisor or job foreman for emergency contact or issues concerning employee(s).

PLEASE TYPE INFORMATION

The following information is supplied and is true and accurate to the best of my knowledge. It is understood that all personnel will receive a background security check.

Printed Name of Submitter: Signature: Date:

WHEN FILLED IN, THIS FORM BECOMES FOUO AND CONTAINS SENSITIVE LAW ENFORCEMENT

AND PRIVACY ACT INFORMTION

SECTION 2

PERSONNEL ROSTER (PLEASE TYPE)

COMPLETE NAME

(LAST, First, Middle)

COMPLETE ADDRESS

(Street, Apt #, City, State, Zip)

LAST 4

Of

SSN

DOB

(MMDDYYYY)

DRIVER’S LICENSE #

(State and Number)

BACKGROUND CHECKS

COMPLETE OUTCOME

Office Use Only

Date Received: Received From:

Security Forces Representative: Signature:

WHEN FILLED IN, THIS FORM BECOMES FOUO AND CONTAINS SENSITIVE LAW ENFORCEMENT

AND PRIVACY ACT INFORMATION.

CONTINUATION PAGE (PLEASE TYPE)

COMPLETE NAME

(LAST, First, Middle)

COMPLETE ADDRESS

(Street, Apt #, city, State, Zip)

Last 4 of

SSN

DOB

(MMDDYYYY)

DRIVER’S LICENSE

(State and Number)

BACKGROUND CHECKS

COMPLETE OUTCOME

CONTINUATION PAGE (PLEASE TYPE)

COMPLETE NAME

(LAST, First, Middle)

COMPLETE ADDRESS

(Street, Apt #, city, State, Zip)

LAST

SSN

DDOB

(MMDDYYYY)

DRIVER’S LICENSE

(State and Number)

BACKGROUND CHECKS

COMPLETE OUTCOME