Attachment_05_-Memorandum_Letter.doc

ATTACHMENT 05

COMPANY LETTERHEAD (If Available)

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

FROM: COMPANY’S NAME/ADDRESS

SUBJECT: Request for Badge/Pass

1. The following individuals require access to Eglin AFB to perform official duties at various buildings at: (A) Eglin main base. Their duties will include (Give brief description of what their duties will be). All work will begin on (date) _24 Sept 12_ and will be accomplished by ___24 Oct 12_. The Eglin AFB contract/BPA number (if applicable) is FA2823-12-P-0097.

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 badge/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 badges of terminated employees and to collect the badges 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

M-F: 0700-1630 999-99-1111//05 May 83/1235897 (AL) *Mary T Lincoln

M-F: 0700-1630

999-99-2222/05 May 83/1234567 (FL) *George B Shaw

999-99-3333/05 May 83/1235897 (AL)

*Sally Smith

999-99-4444/05 May 83/1235897 (AL)

Contractor’s Printed Name

Contractor Signature

Date Signed

MEMORANDUM FOR: 96 SFS/S-5B

FROM: AFTC/PZIO

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/PZIO

Phone #

AFTC/PPZIO/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: