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EGLIN AIR FORCE BASE ACCESS AFFIDAVIT
AUTHORITY: Section 3101, Title 44, United States Code, AFI 33-332, 5 USC 552A
PRINCIPAL PURPOSE(S): Used for requesting personal information to assist security personnel in developing records to document contractor employee suitability for access to Eglin Air Force Base, Florida to work under Air Force contracts. 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 persons desiring access to Eglin Air Force Base as well as for other lawful purposes including law enforcement and litigation. INTENDED USE: All contractors, subcontractors, unit’s or sponsoring activities who have employees not authorized a Common Access Card or security clearance and requires access to Eglin Air Force Base in performance of their official duties, and/or whose contract expires in less than one year. DISCLOSURE: Disclosure of requested information is voluntary. Failure to provide information could result in access privileges being refused or withdrawn.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.
| 1 |
| COMPANY NAME/PHONE NUMBER: |
WORK SITE LOCATION:
TYPE OF WORK (EMPLOYEE):
DAYS OF THE WEEK AND HOURS REQUESTING AUTHORIZATION TO ENTER EGLIN AFB FOR BUSINESS PURPOSES ONLY: (Circle all that apply)
Mon Tues Wed Thurs Fri Sat Sun Earliest entry hour: Latest entry hour:
| 2 |
| LAST NAME (ADD SUFFIX (SR., JR.) : |
| 3 |
| FIRST NAME: |
| MIDDLE NAME: |
| 4 |
| OTHER NAMES ALSO USED (if none, write “NONE”) |
SOCIAL SECURITY NO:
| 5 |
| DATE OF BIRTH (MONTH)______ (DAY) ______ (YEAR) ________ |
| 6 |
| DRIVER LICENSE NO.: |
| STATE: |
| 7 |
| STREET ADDRESS (No P.O. BOXES): |
| HOME PHONE: |
| 10 |
| COUNTRY OF CITIZENSHIP: |
| 11 |
| RESIDENT ALIEN NO. OR IMMIGRATION DOCUMENT NO. AND DESCRIPTION: |
| 13 |
| BIRTHPLACE (CITY/STATE/COUNTRY): |
| 14 |
| MALE: _____ |
| FEMALE: ______ |
| RACE: |
| 15 |
| HAIR COLOR: |
| EYE COLOR: |
| HEIGHT: |
| WEIGHT: |
| 16 |
| PHYSICAL BODY CHANGES OR TATTOOS: |
The information on this form is being collected in accordance with, federal law permitting the installation commander to limit access to the installation for security reasons (50 U.S.C. Section 797 and DoD Directive 5200.8). This data will be used to screen individuals who have or are seeking access to Eglin Air Force Base, Florida. Failure to provide truthful, complete and accurate responses may be used as a basis to deny entry to Eglin Air Force Base and is also punishable as a criminal offense.
Please answer each of the following questions by circling the correct answer. The information you provide will be verified through state and federal criminal history record checks.
| Can U.S. citizenship, immigration status, or Social Security Account Number be verified? |
| YES |
| NO |
| Have you ever been barred from entry/access to any Federal/military installation or facility? |
| YES |
| NO |
| Are you wanted by federal or civil law enforcement authorities, regardless of offense/violation (i.e., an “order to arrest” has been issued by a judge)? |
| YES |
| NO |
| Have you been incarcerated for 12 months or longer within the past ten years, regardless of offense/violation, unless released on proof of innocence? |
| YES |
| NO |
| Have you ever been convicted of espionage, sabotage, treason, terrorism or murder? |
| YES |
| NO |
| Does your name appear on any federal agency’s “watch list” or “hit list” for criminal behavior or terrorist activity? |
| YES |
| NO |
| Are you unable to obtain a favorable National Agency Check w Inquiries (NACI)? |
| YES |
| NO |
| Have you been convicted of firearms or explosives violation within the past ten years? |
| YES |
| NO |
| Have you been convicted of sexual assault, armed assault/robbery, rape, child molestation, drug possession with intent to sell, drug distribution, or trafficking in humans? |
| YES |
| NO |
| Are you a registered sex offender? |
| YES |
| NO |
| Have you been convicted of 10 or more habitual felonies within the past ten years? |
| YES |
| NO |
| Are you an undocumented, non-U.S, citizen (Foreign National)? |
| YES |
| NO |
| Have you ever conspired or attempted to commit any of the criminal acts listed above? |
| YES |
| NO |
NOTE TO APPLICANT: ATTESTATION
I understand that by signing this application, 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 barment from the installation, a fine, imprisonment or both. (18 U.S.C. Section 1001).
Further, 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 Eglin Air Force Base, within 24 hours, if I am convicted or found not guilty by reason of insanity of any of the above criminal offenses that occurs while I have unescorted access authority within Eglin Air Force Base.
I understand if my access privileges are denied I have the right to appeal the decision. Contact Supervisor, Pass and Registration at (850) 882-9903 for guidance.
Applicant Name_________________________________________________________
(Print legibly)
Applicant Signature______________________________________________________
Date____________________________
Company Name_________________________________________________________
Company Representative: ______________________________________________________
Printed Name Signature
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