Attachment_10-_Base_Access_Memorandum_Template.pdf

COMPANY LETTERHEAD (If Available) Date

MEMORANDUM FOR: 96 SFS/S-5B through AFTC/PZIOC

FROM: COMPANY’S NAME/ADDRESS

SUBJECT: Request for Badge/Pass

1. The following individuals require temporary access to Eglin AFB to submit a proposal at the Source Selection Facility Building 373. Access will only be required for one day; (date) __________. The Eglin AFB solicitation number is FA2823-14-R-6024.

2. The individuals listed have been briefed that while on the installation they must comply with all local laws and policies. The failure to comply will result in loss of base access. Each individual understands that they must go to the Security Forces Pass and Registration Office (East Gate Visitor’s Center) to receive their contractor identification pass. They further understand they must have a valid drivers license/Identification card, proof of current registration and insurance while driving on the installation.

3. When first arriving to the installation the following individuals will need No escort before being allowed access to the installation

4. I understand it is the contractor’s responsibility to collect the passes of terminated employees and to collect the passes at the conclusion of the work that was to be accomplished. Further, I understand that the contractor is responsible to turn the badges/passes in to the Security Forces Pass and registration office as soon as all work is complete.

Name of Individual Days/hrs of access SSN/Date of Birth /Drivers Licence #/State *John Q Doe Jr 24/7 999-99-1111//05 May 83/1235897 (AL) *Mary T Lincoln M-F: 0600-2100 999-99-2222/05 May 83/1234567 (FL) *George B Shaw M-Sa: 0500-2200 999-99-3333/05 May 83/1235897 (AL) *Sally Smith Tu, Th: 1700-2100 999-99-4444/05 May 83/1235897 (AL)

Contractor’s Printed Name Contractor Signature Date Signed

MEMORANDUM FOR: 96 SFS/S-5B

FROM: AFTC/PZIOC

The contracting office hereby verifies that the above contractor has an active contract and requires access to the base installations.

Name/ SSN Contract Specialist

AFTC/PZIOC _____________________________________________

Phone # AFTC/PZIOC/Contracting Office Representative Signature

Authority: 10 U.S.C.8013, Secretary of the Air Force Purpose: Used by the Security Forces for issuing ID media. Some organizations may routinely keep copies of the above documentation in order to maintain control over persons authorized entry into certain areas. Accountability documents are used to insure proper control over the various forms utilized in these functions.

Routine Use: In addition to those disclosures generally permitted under 5 U.S.C. 552(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C.552a(b)(3) as follows: