CRTC ACCESS APPLICATION (Contractor Affidavit).pdf

MISSISSIPPI COMBAT READINESS TRAINING CENTER ACCESS APPLICATION

Section II. APPLICANT'S PERSONAL INFORMATION

1. NAME (Last, First, Middle) 2. SSN 3. DOB (YYYYMMDD)

4. CURRENT RESIDENCE ADDRESS (Include City/State/ZIP Code) 5. LOCAL PHONE #

6. SEX 7. RACE 8. EYE COLOR 9. HAIR COLOR 10. HEIGHT 11. WEIGHT

Section III. APPLICANT'S PLACE OF BIRTH AND STATE IDENTIFICATION

1. CITY 2. STATE 3. COUNTRY

5. DRIVER'S LICENSE/ID NUMBER 6. LICENSE EXPIRATION DATE

Section IV. APPLICANT - PLEASE ANSWER THE FOLLOWING QUESTIONS: YES NO

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

2) Are you wanted by federal or civilian law enforcement authorities, regardless of offense or violation (i.e., has a judge issued an order for your arrest)?

3) Have you ever been incarcerated or arrested regardless of offense or violation?

4) Have you ever been convicted of a firearms or explosive violation within the past ten years?

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

IF YOU ANSWERED YES TO ANY OF THE ABOVE, PLEASE PROVIDE A FULL EXPLANATION:

Applicant Signature: ______________________________________ Date:_______________

Company Name: ______________________________________________

MS CRTC Access Application (3 Feb 2020) Page 1 of 2

I hereby authorize the use and release of my personal information to MS CRTC Security Forces Police Services Office to accomplish criminal background checks to determine eligibility for unescorted access to MS CRTC. I will promptly return all credentials when they are no longer needed for my assigned duties or upon request by proper authority.

Section I. SPONSORING ORGANIZATION (COMPLETED BY DESIGNATED DOD GOVERNMENT SPONSOR ONLY)

Normal base hours of operation are from 0700-1630. Contractors working different hours must be noted below:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Entry Hour

Departure Hour

CONTRACT NUMBER

CONTRACT EXPIRATION DATE

DEPARTMENT OF DEFENSE GOVERNMENT SPONSOR:

Signature

Date

Print namet name

Department

4. US CITIZEN?

YES Y NO

7. STATE OF ISSUE

Section V. PRIVACY ACT STATEMENT

Page 2 of 2 MS CRTC Access Application (3 Feb 2020)

The public reporting burden for this collection of information is estimated to take three 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.

Once application is completely filled in and signed, the DoD Government Sponsor may submit it via encrypted e-mail to:

usaf.ms.ms-crtc.mbx.mscrtc-security-forces-pso1@mail.mil OR hand deliver to MS CRTC Police Services (Building 4).

Section VI. AGENCY DISCLOSURE

Authority: 18 USC Section 1001; 50 USC Section 797; EO 9397; DoDD 5200.8

PRINCIPAL PURPOSE(S): The purpose for requesting personal information is to assist Security Forces personnel in documenting contractor employee suitability for access to USAF installations. The Social Security Number (SSN) 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 Gulfport, MSCRTC;

as well as, for lawful purposes including law enforcement and litigation. This information will be used to generate state and federal criminal history records checks.

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

DISCLOSURE: Disclosure of requested information is voluntary; however, failure to provided 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.

INFORMATION PROTECTION: All Personally Identifiable Information (PII) will be protected pursuant to the Privacy Act of 1974, DoD and USAF privacy programs.

Section VII. REMARKS