NBAFS_visitor_access_application.pdf

[1] Rev 27 Aug 13

SFNOTES:

NEW BOSTON AIR FORCE STATION VISITOR ACCESS APPLICATION

(SUBJECT TO THE PRIVACY ACT OF 1974)

PRIVACY ACT STATEMENT

AUTHORITY: E.O. 9397; The Privacy Act of 1974, 5 U.S.C. 522a; DODD 8500.1 PRINCIPAL PURPOSE(S): To provide necessary information to 23 SOPS/SF to determine if applicant meets access control requirements IAW HSPD12, DoD 5200.8, DTM 09-12 and FIPS201. Use of SSN is necessary to make positive identification of an applicant. Records in the Defense Biometric Identification System (DBIDS) are maintained to support DoD physical security and information assurance programs and are used for identity verification purposes, to record personal property registered with the DoD and for producing facility management reports. SSN, Drivers License Number or other acceptable identification will be used to distinguish individuals who request entry to 23 SOPS/NBAFS property.

DISCLOSURE: Voluntary. However, failure to provide the requested information may result in denial of a badge or visitor pass and denial of entry to 23 SOPS/NBAFS property.

I. IDENTIFICATION

NAME( Last, First, Middle Initial, Suffix)

BIRTH( YYYY/MM/DD) SOCIAL SECURITY NO

DRIVER’S LICENSE NUMBER STATE COMPANY NAME/RELATION SHIP TO SPONSOR

PHONE NUMBER SPONSOR NAME SPONSORS PHONE NUMBER

US CITIZEN? ALIEN/PASSPORT/BIRTH COUNTRY(Non-US Citizen) GENDER

HEIGHT(In)

WEIGHT

EYE COLOR HAIR COLOR

YES

NO

ACTIVE

CLEARANCE

VALID CAC

CARD

HOLDER

VALID TWIC

CARD

HOLDER

Notes/Additional info:

II. PAST OR PRESENT CONVICTIONS

All contractor/visiting personnel requiring access to New Boston Air Force Station (NBAFS) will undergo a National Crime Information Center (NCIC) and criminal history check. This check will be conducted by 23 SOPS/SF at no cost to contractor/visiting personnel. Results of the criminal history check will be maintained by SF personnel. Refusal to submit to the NCIC check or report of adverse information will result in denial of access of the person. The check will include a scope of ten (10) years. Examples of disqualifying reports or convictions are listed on page three (3) of this form.

DO YOU HAVE ANY CURRENT OR PAST FELONIES THAT WOULD PREVENT A FAVORABLE BACKGROUND CHECK? YES NO

III. IDENTITY PROOFING

All Visitors are required to produce two (2) forms of government-issued identification (IAW the USCIS & DHS I-9 Form listed on page 4) at the Pass & Registration Office located at Building 103 upon initial entry to the installation in order to facilitate identity proofing. Failure to produce two (2) forms of government-issued identification may lead to being denied entry to the installation. A copy of the I9 form can be found at: http://www.uscis.gov

IV. VEHICLE REQUIRMENTS/PRIVATELY OWNED FIRE ARMS

All vehicles operators entering NBAFS are required to have a valid driver's license, current registered, inspected vehicle/trailers with proof of valid vehicle insurance readily available. Operators who are not able to produce these documents may be denied entry or issued a traffic citation. Possession of Privately Owned Firearms is prohibited on NBAFS except when engaged in a specific recreational activity authorized by the Installation Commander.

V. ATTESTATION

I understand that under the authority of 50 U.S.C. Section 797 and DoDD 5200.8, the installation commander has imposed a continuing obligation for me to disclose to NBAFS, within 24 hours, if I am convicted or found not guilty by reason of insanity of any of the criminal offenses listed on page three (3) that occurs while I have unescorted access authority on New Boston Air Force Station.

The information I have provided on this application is true, complete, and correct to the best of my knowledge and belief and is provided in good faith. I understand that a knowing and willful false statement on this application can be punished by a fine or imprisonment or both. (18 U.S.C. Section 1001).

SIGNATURE DATE

VI. 23 SOPS/SF USE ONLY

DATE OF NCIC COMPLETED BY RESULTS

[2] Rev 27 Aug 13

INSTRUCTIONS FOR COMPLETING 23 SOPS/SF FORM (Must be typed or printed clearly in ink).

I. Identification Section

Name – Enter individuals Last Name, First Name and Middle Initial Jr, II, Sr, III.

Birth – Date of Birth using YYYY/MM/DD format IE: (2013/12/01).

Social Security Number – Enter the individual’s social security number.

Driver’s License/State – Enter individual’s complete driver’s license number and state issued.

Company Name/ relationship to Sponsor - Enter your company name or relationship to Sponsor.

Phone Number - Enter your contact number

Sponsor’s Name – NBAFS Sponsor’s Name

Sponsor’s Phone Number – NBAFS Sponsor’s Name

US Citizen – Check either Yes or No is the individual is a US citizen

Alien Passport – Used to document Alien, Passport or immigration number of non-US citizens

Gender – Enter either M or F

Height – Enter height of individual in feet and inches, e.g. 5’8”

Weight – Enter weight in pounds, e.g. 175

Eye Color – Enter individual’s eye color, e.g. Black, Blue, Gray, Green, Hazel, Violet

Hair Color – Individual’s hair color, e.g. Auburn, Black, Blond, Gray, Red, Silver, White

Active Clearance- Do you currently have an Active Government Security Clearance (IE: Secret/Top Secret).

CAC Card- Do you currently have a United States Government Common Access Card.

TWIC CARD- Do you currently have a Transportation Workers Identification Card.

Notes – Add any additional Notes/Comments you might have to assist in determining your eligibility for access.

II. Past or Present Convictions.

See page 3 for a list of disqualifying events.

III. IDENTITY PROOFING.

Review Requirements

IV. VEHICLE REQUIRMENTS/PRIVATELY OWNED FIRE ARMS.

Review Requirements

V. Attestation

Signature - Sign

Date - Date Signed

VI. 23 SOPS/SF use only

Internal use only.

Directions for Submitting: Page one (1) of this form may be delivered to either the Pass & Registration Office (Bldg. 103), faxed to (603) 471-2105 or scanned and emailed to sfanewboston@us.af.mil. Allow five (5) duty days for processing.

[3] Rev 27 Aug 13

Installation Commanders may deny access and access credentials based on information obtained during identity vetting that indicates the individual may present a threat to the good order, discipline and morale of the installation, including, but not limited to the following:

The individual is known to be or reasonably suspected of being a terrorist or belongs to an organization with known terrorism links/support.

The installation is unable to verify the individual's claimed identity.

There is a reasonable basis to believe the individual has submitted fraudulent information concerning his or her identity.

There is a reasonable basis to believe the individual will attempt to gain unauthorized access to classified documents, information protected by the Privacy Act, information that is proprietary in nature, or other sensitive or protected information.

There is a reasonable basis to believe the individual will unlawfully or inappropriately use an access credential outside the workplace.

There is a reasonable basis to believe, based on an individual's criminal or dishonest history, that issuance of an access credential poses an unacceptable risk to the installation/mission.

The individual has/had been barred from entry/access to a Federal installation or facility.

The individual is wanted by Federal or civil law enforcement authorities, regardless of offense or violation.

The individual has been incarcerated within the past ten years, regardless of offense/violation, unless released on proof of innocence.

The individual has any conviction for espionage, sabotage, treason, terrorism, or murder.

The individual’s name appears on any Federal or State agency’s “watch list” or “hit list” for criminal behavior or terrorist activity.

The individual has been convicted of a firearms or explosive violation within the past ten years.

The individual has been convicted of sexual assault, armed robbery, rape, child molestation, child pornography, trafficking in humans, drug possession with intent to sell or drug distribution.

There is a reasonable basis to believe, based on the individual's material, intentional false statement, deception, or fraud in connection with Federal or contract employment, that issuance of an access credential poses an unacceptable risk to the installation/mission.

There is a reasonable basis to believe, based on the nature or duration of the individual's alcohol abuse without evidence of substantial rehabilitation, that issuance of an access credential poses an unacceptable risk to the installation/mission.

There is a reasonable basis to believe, based on the nature or duration of the individual's illegal use of narcotics, drugs, or other controlled substances without evidence of substantial rehabilitation, that issuance of an access credential poses an unacceptable risk to the installation/mission.

A statutory or regulatory bar prevents the individual's contract employment; or would prevent Federal employment under circumstances that furnish a reasonable basis to believe that issuance of an access credential poses an unacceptable risk to the installation/mission.

The individual has knowingly and willfully engaged in acts or activities designed to overthrow the U.S. Government by force.

[4] Rev 27 Aug 13