Attachment_12_Eglin_AFB_FORM_90_Base_Access.pdf

EGLIN AFB FORM 90, 20130911

EGLIN AIR FORCE BASE ACCESS AFFIDAVIT

AUTHORITY:

COMPANY

FOR OFFICIAL USE ONLY WHEN FILLED IN

NAME PHONE

Section 3101, Title 44, United States Code, AFI 33-332, 5 USC 552A.

PURPOSE: 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 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.

ROUTINE USES: All contractors, subcontractors, units or sponsoring activities who have employees not authorized a Command 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 Failure to provide information could result in access privileges being refused or withdrawn.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.

PRIVACY ACT STATEMENT

WORK SITE LOCATION TYPE OF WORK(Employee)

AUTHORIZATION TO ENTER EGLIN AFB FOR BUSINESS PURPOSES ONLY

DAYS OF WEEK(Check on that Apply) HOURS

MONDAY TUESDAY WEDNESDAY THURSDAY

FRIDAY SATURDAY SUNDAY

EARLIEST ENTRY HOUR

LATEST ENTRY HOUR

CONTRACTOR

NAME SSN(Last, First, Middle (Add Suffix Sr., Jr. after last name))

OTHER NAMES ALSO USED (If none, write "NONE")

DATE OF BIRTH DRIVER LICENSE NUMBER STATE

STREET ADDRESS CITY

HOME PHONE

(No P.O. Boxes) STATE ZIP CODE

RESIDENT ALIEN NUMBER OR IMMIGRATION DOCUMENT NUMBER AND DESCRIPTION

BIRTHPLACE (City/State/Country) COUNTRY OF CITIZENSHIP

MALE

FEMALE

RACE HAIR COLOR EYE COLOR HEIGHT WEIGHT

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. 797 AND DoD INSTRUCTION 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.

PHYSICAL BODY CHANGES OR TATTOOS

FOR OFFICIAL USE ONLY WHEN FILLED IN

EGLIN AFB FORM 90, 20130911

FOR OFFICIAL USE ONLY

PLEASE ANSWER EACH OF THE FOLLOWING QUESTIONS BY CHECKING THE CORRECT ANSWER. THE INFORMATION YOU PROVIDE WILL BE VERIFIED

THROUGH STATE AND FEDERAL CRIMINAL HISTORY RECORD CHECKS.

YES NO

FOR OFFICIAL USE ONLY

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 WANTED BY FEDERAL OR CIVILIAN LAW ENFORCEMENT AUTHORITIES, REGARDLESS OF OFFICE/VIOLATION

(i.e., an "order to arrest" has been issued by a judge)

HAVE YOU BEEN CONVICTED OF ANY OFFENSE THAT INVOLVED VIOLENCE IN THE WORKPLACE?

HAVE YOU BEEN CONVICTED OF ANY VIOLENT CRIMINAL OFFENSE THAT RESULTED IN DEATH?

HAVE YOU BEEN CONVICTED OF ANY OFFENSE THAT INVOLVED USE OF A WEAPON?

HAVE YOU BEEN INCARCERATED FOR 12 MONTHS OR LONGER , REGARDLESS OF OFFENSE/VIOLATION, UNLESS

RELEASED ON PROOF OF INNOCENCE?

HAVE YOU EVER BEEN CONVICTED OF ESPIONAGE, SABOTAGE, TREASON, OR TERRORISM OR MURDER?

DOES YOU NAME APPEAR ON ANY FEDERAL AGENCY'S "WATCH LIST" OR "HIT LIST" FOR CRIMINAL BEHAVIOR OR

TERRORIST ACTIVITY?

HAVE YOU BEEN PREVIOUSLY DENIED ACCESS TO ANY DOD INSTALLATIONS?

HAVE YOU BEEN CONVICTED OF FIREARMS OR EXPLOSIVES VIOLATION?

HAVE YOU BEEN CONVICTED OF SEXUAL ASSAULT/ROBBERY, RAPE, CHILD MOLESTATION, DRUG POSSESSION WITH

INTENT TO SELL, DRUG DISTRIBUTION, OR TRAFFICKING IN HUMANS?

ARE YOU A REGISTERED SEX OFFENDER?

ARE YOU AN UNDOCUMENTED, NON-US., CITIZEN (FOREIGN NATIONAL)?

I UNDERSTAND THAT BY SIGNING THIS APPLICATION, THE INFORAMTION 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).

NOTE TO APPLICANT: ATTESTATION

FURTHER, I UNDERSTAND THAN UNDER THE AUTHORITY OF 50 U.S.C. SECTION 797 AND DoDI 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 OR THE ABOVE CRIMINAL OFFENSES THAT OCCURS WHILE I HAVE UNESCORTED ACCESS

AUTHORITY WITHIN EGLIN AIR FORCE BASE.

APPLICANT NAME

APPLICANT SIGNATURE

COMPANY NAME

COMPANY REPRESENTATIVE NAME

COMPANY REPRESENTATIVE SIGNATURE

(print legibly)

DATE