Attachment_5_EAFB_Form_90.pdf

FOR OFFICIAL USE ONLY WHEN FILLED IN

EGLIN AIR FORCE BASE ACCESS AFFIDAVIT

PRIVACY ACT STATEMENT

AUTHORITY: 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 Failure to provide information could result in access privileges being refused or withdrawn.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.

COMPANY

NAME PHONE

WORK SITE LOCATION

Eglin AFB Building

TYPE OF WORK(Employee)

AUTHORIZATION TO ENTER EGLIN AFB FOR BUSINESS PURPOSES ONLY

DAYS OF WEEK(Check on that Apply)

MONDAY TUESDAY

FRIDAY SATURDAY

WEDNESDAY THURSDAY

SUNDAY

HOURS 9:00am to 11:30am

EARLIEST ENTRY HOUR 9:00am

LATEST ENTRY HOUR 11:30am

CONTRACTOR

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

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

DATE OF BIRTH DRIVER LICENSE NUMBER

STATE

BIRTHPLACE (City/State/Country) COUNTRY OF CITIZENSHIP

RESIDENT ALIEN NUMBER OR IMMIGRATION DOCUMENT NUMBER AND DESCRIPTION

STREET ADDRESS (No P.O. Boxes) CITY STATE ZIP CODE

MALE

FEMALE

RACE HAIR COLOR EYE COLOR HEIGHT WEIGHT

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. 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.

EGLIN AFB FORM 90, 20130911

FOR OFFICIAL USE ONLY WHEN FILLED

IN

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

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)?

NOTE TO APPLICANT: ATTESTATION

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).

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 (print legibly)

APPLICANT SIGNATURE DATE

COMPANY NAME

COMPANY REPRESENTATIVE NAME

COMPANY REPRESENTATIVE SIGNATURE

EGLIN AFB FORM 90, 20130911

FOR OFFICIAL USE ONLY