2012_Base_Access_Affidavit.pdf

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 Forcecontracts. The Social Security Number (SSN) and Date ofBirth (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 Failure to provide information could result in access privileges being refused or withdrawn.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 ActStatement will apply throughout the duration of the Air Force contract while servingin the capacityof prime contractor or subcontractor/supplier employee.

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:

LAST NAME (ADD SUFFIX (SR., JR.):

FIRST NAME:

OTHER NAMES ALSO USED (if none, write

"NONE")

DATE OF BIRTH (MONTH). (DAY)

DRIVER LICENSE NO.:

STREET ADDRESS (No P.O. BOXES):

CITY:

STATE: ZIP:

COUNTRY OF CITIZENSHIP:

MIDDLE NAME:

SOCIAL SECURITY NO:

(YEAR)

STATE:

HOME PHONE:

RESIDENT ALIEN NO. OR IMMIGRATION DOCUMENT NO. AND DESCRIPTION:

BIRTHPLACE (CITY/STATE/COUNTRY):

MALE: FEMALE: RACE:

HAIR COLOR: EYE COLOR: HEIGHT: WEIGHT:

PHYSICAL BODY CHANGES OR TATTOOS

The information on this form is beingcollected 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 willbe used to screen individuals who have or are seekingaccess 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 answereach 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?

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

Are you wantedby federal or civil law enforcementauthorities, regardless of offense/violation (i.e., an "order to arrest" has been issued by a judge)?

Have you been incarcerated for 12 months or longerwithin the pastten years, regardless of offense/violation, unless released on proof of innocence?

Have you ever been convicted of espionage, sabotage, treason, terrorism or murder?

Does your name appear on any federal agency's"watch list" or"hit list" for criminal behavior or terrorist activity?

Are you unable to obtain a favorable National Agency Check w Inquiries (NACI)?

Have you been convicted of firearms or explosives violation within the past ten years?

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?

Are you a registered sex offender?

Have you been convicted of 10 or more habitual felonies within the past ten years?

Are you an undocumented, non-U.S, citizen (Foreign National)?

Have you ever conspired or attempted to commit any of the criminal acts listed above?

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

NOTE TO APPLICANT: ATTESTATION

I understand that by signingthis application, the information I have providedon this applicationis true, complete,and correct to the bestof my knowledge and beliefand is provided in good faith. I understand that a knowingand willful false statement onthisapplication canbe punished by barment fromthe installation, a fine, imprisonment or both. (18 U.S.C. Section 1001).

Further, I understand that under the authority of50U.S.C. Section797 and DoDD 5200.8,the installation commander has imposed a continuing obligation forme to disclose to Eglin Air Force Base, within24hours,if I am convicted or found not guilty by reason of insanity of anyof the above criminal offenses that occurs while I haveunescorted access authoritywithin Eglin Air Force Base.

I understand if my access privileges are denied I have the right to appealthe decision. Contact Supervisor,Passand Registration at (850)882-9903 for guidance.

Applicant Name (Print legibly)

Applicant Signature '.

Date

Company Name.

Company Representative:

Printed Name Signature