14. Base Pass Forms.pdf

[Type text]

FA3020-10-R-0041

Attachment 14

APPLICATION FOR PERSONNEL AND VEHICLE PASSES TO WORK UNDER AIR FORCE CONTRACT

(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)

INSTRUCTIONS

1. Submit one copy to 82 SFS. Original to Employee. All information must be completed; Spell out First, Middle, and Last Names (no initials).

2. Employee must present INS identification if pertinent, Social Security Card, Birth Certificate, and a Driver's License to be considered as a valid form of identification.

Vehicle operators will need a copy of vehicle registration and certificate of automobile insurance.

SECTION I: Contractor must ensure all blocks are complete.

1.1. THRU (CONTRACTING OFFICE/SPONSORING ACTIVITY ADDRESS)

1.2. FROM (PRIME CONTRACTOR'S NAME, ADDRESS, PHONE)

1.3. CONTRACT NUMBER

1.4. CONTRACT EXPIRATION DATE

1.5. DAYS/HOURS WORKED

1.6. PLACE OF DUTY/WORK/BLDG

Employee Information Vehicle Information

(If company owned vehicle put N/A)

1.7. NAME (LAST, FIRST, MIDDLE)

1.8. SOCIAL SECURITY #

1.9. DATE

OF BIRTH

1.10. DRIVER LIC NO/

STATE

1.11. MAKE/MODEL/YEAR

1.12. PLATE

NO/STATE

THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED

STATES CODE, SECTION 1001 OR OTHER APPLICABLE LAWS AND REGULATIONS.

NOTE: "CONTRACTOR AND EMPLOYEE" SHALL RETURN BADGE TO SF PASS & ID UPON EXPIRATION OR TERMINATION OF CONTRACT

1.13. EMPLOYEE SIGNATURE: _____________________________________________________________ DATE: ____________________________

1.14. PRIME CONTRACTOR CERTIFICATION: Employer certifies that employee is working on the above contract.

PRIME CONTRACTOR'S SIGNATURE: ___________________________________________________ DATE: ____________________________

1.15. IF EMPLOYEE IS A SUBCONTRACTOR EMPLOYEE: Complete below

1.15.1. Sub-Contractor Company Name: _____________________________________________________________________________________________________

1.15.2. Sub-Contractor's Address and Phone: ________________________________________________________________________________________________

SECTION II: To be completed by Contracting Office/Sponsoring Activity (same as Section I, Block 1.1. THRU) THIS IS TO CERTIFY: I have verified that the individual above is performing in an official capacity on referenced contract and/or requires a badge in the performance of their official duties on Sheppard AFB in accordance with the contract terms and conditions.

2.1. Contracting Officer Name & Phone Phone Number: ______________________________________________

2.2. Length of Pass 8 to 89 days, 90 days to 1yr, 2 yrs, 3 yrs Start Date: ________________

2.3. SIGNATURE: _____________________________________________________________ DATE: _____________________________________________

SECTION III: To be completed by Security Forces Pass & ID 3.1.

Fingerprints Taken? Yes No

TLETS Check Conducted? Yes No

3.2. Badge Type

Contractor: _____ Yes _____ No

Vendor: _____ Yes _____ No

Other: _____ Yes _____ No

3.3. Date Issued

3.4. Date Expires

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 8013, Secretary of the Air Force: Power and Duties; delegate by

PRINCIPLE PURPOSE(S): The purpose for requesting personal information is to assist security personnel in developing records to document contractor employee suitability for access to Sheppard AFB, TX to work under Air Force contracts. The Social Security Number (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 Sheppard AFB as well as for other lawful purposes including law enforcement and litigation.

INTENDED USE: All contractors, subcontractors, units of Sheppard AFB sponsoring activities who have employees not authorized a Common Access Card and requiring regular and frequent access to Sheppard AFB in performance of their official duties.

DISCLOSURE: Disclosure of requested information is mandatory. Failure to provide information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of Air Force contract while serving in the capacity of prime contractor or subcontractor/supplier employee.

SHEPPARD AFB FORM 151, 20070801

Attachment 14

CONTRACTOR/SUBCONTRACTOR ACCESS AFFIDAVIT

SUBMIT WITH PASS & ID PAPERWORK

(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)

INSTRUCTIONS

1. Submit one copy to 82 SFS. Original to Employee. This data will be used to screen individuals who have or are seeking access to US Air Force installations or facilities controlled by the US Air Force. Please answer each question. Access will be denied if this questionnaire is incomplete or missing from the Contractor Access Packet. This Information will be used to generate state and federal criminal history records checks.

1. NAME

(Last, First, Middle)

2. SEX

3. SSAN 4. DATE OF BIRTH (YYYYMMMDD) 5. RACE

6. SCARS/MARKS/TATTOOS

7. HAIR COLOR

8. EYE COLOR

9. HEIGHT

10. WEIGHT

11. ALIAS

12. DRI VER LICENSE #

13. STATE

14. CURRENT RESIDENCE

ADDRESS

15. CITY

16. STATE

17. ZIP CODE

18. COUNTRY

PLACE OF BIRTH

19. CITY

20. STATE (If Applicable)

21. COUNTRY

22. CITIZENSHIP

23. RESIDENT ALIEN # OR IMMIGRATION DOCUMENT # and DESCRIPTION

PLEASE ANSWER THE FOLLOWING QUESTIONS:

YES NO

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

Are you wanted by federal or civilian law enforcement authorities, regardles of offense or violation (i.e., has a judge issued an order for your arrest?

Have you ever been incarcerated for 12 months or longer within the past three years, regardless of offense or violation?

Have you ever been convicted of a firearms or explosive violation within the past three years?

Have you ever been convicted of espionage, sabotage, treason or terrorism, murder, sexual assault, armed assault or robbery, rape, child molestation, felony drug possession with intent to sell or drug distribution?

IF YOU ANSWER YES TO ANY OF THE ABOVE, PLEASE PROVIDE A FULL EXPLANATION:

SHEPPARD AFB FORM 150, 20070801

Attachment 14

NOTE TO APPLICANT: ATTESTATION

I attest to the fact that I have been briefed by my employer and understand the purpose for the contractor background check. I understand the information on this form is being collected in accordance with 50 U.S.C., Section 797, and DoDD 5200.8 federal laws permitting the installation commander to limit access to the installation for security reasons and that this data will be used to screen DoD contractors employees who have or are seeking access to US Air Force installations. I have voluntarily completed this "Form" and shall provide the Air Force a specimen of my fingerprints, if/when requested. I understand that by signing this application, I acknowledge that I have been made aware of and have reviewed the list of Sheppard AFB "Disqualifying Factors" above. I hereby give my consent and authorization for the Air Force to conduct any additional background screenings deemed necessary over the next 24 months, unless other wise directed by 82 CONS, to included comparing/checking my fingerprints against local state, and federal criminal databases. The information 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 willfully false statement on this application can be punished by fine or imprisonment or both (18 U.S.C Section 1001).

Applicant Signature ________________________________________ Date: ________________

Company Name: _______________________________________________

Privacy Act Statement

AUTHORITY: Section 3101 Title 44, United States Code, AFI 33-32, 552A PRINCIPAL PURPOSE(S): The purpose for requesting personal information is to assist police personnel in documenting contractor employee suitability for access to USAF installations. The Social Security Number (SSAN) and Date of Birth (DOB) are necessary to identify the person and records. This information may be used to determine suitability of person desiring access to the installation as well as for lawful purposes including law enforcement and litigation.

INTENDED USE: For all contractors and subcontractors who are not authorized a Common Access Card (CAC) and require regular and frequent access to the installation in performance of their official duties DISCLOSURE: Disclosure of requested information is mandatory. Failure to provided information will 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.

AGENCY DISCLOSURE

The public reporting burden for this collection of information is estimated to take 3 to 30 days per response, including the timeframe for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information.

PASS & ID USE ONLY

Approve

Disapprove

Reason: