Attachment_4_-_Base_Pass_Request.pdf

REQUEST FOR BACKGROUND CHECK AND/OR BASE PASS

TO: FROM: (CONTRACTOR PROVIDE PHONE NUMBER) DATE:

27 SOSFS/S5P

27 SOCONS/LGCB

110 E. Alison Ave Bldg 600 Cannon AFB, NM 88103 (575-784-1359)

Date completed

1. Request the individual and vehicle (if applicable) listed below be granted access to Cannon AFB for the performance of contract work. The following actions are requested (please check the applicable blocks below).

X Background Check X Worker Pass Sponsor Pass Renewal

2. CONTRACT EMPLOYEE AND VEHICLE INFORMATION

CONTRACT EMPLOYEE’S NAME SSAN DOB (MMDDYYYY) EMPLOYER (CONTRACTOR COMPANY)

COMPLETE ADDRESS HOME PHONE or CELL (TO INCLUDE AREA CODE) WORK PHONE (TO INCLUDE AREA CODE)

DRIVER’S LICENSE OR ID NUMBER (State DL or ID) STATE PLACE OF BIRTH

3. PASS INFORMATION

PASS DATES (NOT TO EXCEED 1 YEAR)

(00 XXX 2017)

AUTHORIZED DAYS (i.e., Mon-Fri) AUTHORIZED HOURS (i.e., 0700-1600) DESTINATION (i.e., Bldg xxx, R/W xxx)

The above named individual was instructed that this pass is to be used for entry onto Cannon AFB for the sole purpose of completing contract work assignments only. He/she was further instructed that this pass does not authorize any base privileges (i.e., Base Exchange, Shoppette, Golf etc.).

At the time of requesting above pass, the individual must have in their possession their social security card and a valid state, or federal form of picture identification. If requesting to drive on CAFB the individual must have a valid driver's license, insurance documents, and vehicle registration.

All sponsoring agencies are responsible for passes issued under their contract. When a contract is terminated or an employee is terminated or quits, the pass is to be recovered by the sponsoring agency and returned to Pass & Registration. In the event the sponsor is unable to retrieve the pass from a terminated employee, the sponsor must notify Pass & Registration in writing the next duty day.

FULL NAME OF PERSON AUTHORIZED TO SIGN REQUESTS DUTY PHONE SIGNATURE DATE (00 xxx 2016)

4. ENDORSER (TO BE COMPLETED BY PASS & REGISTRATION PERSONNEL)

CLERK WHO FILLED PASS PASS NUMBER DATE ISSUED

Please fill out below if the pass is a second issue (to be completed by Pass & Registration clerk).

SECOND ISSUE: CLERK WHO FILLED PASS PASS NUMBER DATE ISSUED

PRIVACY ACT NOTICE

Privacy Act 1974 as Amended may apply--this communication contains personal information which must be protected IAW DOD

5400.11R, and is FOR OFFICIAL USE ONLY (FOUO) 11 Jul 14