JB CHS Base Access Form.pdf

Joint Base Charleston (JB CHS) Worksheet for Base Access Applicant Complete Name

As it appears on identification

(Last, First, Middle)

Applicant Complete Address

(Street, Apt Number, City, State, Zip) Applicant

SSAN

App DOB

(MM/DD/YY)

Place of Birth

App Driver’s License or ID Card # and State of issue

NCIC History

Log

Date Pass

Issued

BADGE

Issued

#1 Company: ____________________________________________________ #2 (Sub): _________________________#3 Job Site Phone #: __________________ Personal Phone #: _______________

#4 Company Phone # (on base #) #5 Days & Times Access is required: _______________________________________________________

#6 : Description of Work to be performed: ____________ Bldg No: _________

#7 Company Address: _________________________________________________________________________________________________________________________________

#8 Prime Contractor’s Name (if applicable): ____________________________________ #9 Contract for/service provided: ___________________________________________________

#10 Location of work to be performed: _________________________________________________________________ #11 Prime Contract Number: _______________________________

#12 Start Date: _____________ #13 End Date: ____________ #14 Base Sponsoring Unit: ______________________ #15 Base Sponsor Info: ____________________________________

(Rank/Name/Phone)

#16 Are you a U.S. citizen? Yes No #17 Attach legible copy of state driver’s license or state ID card with clear photo

#18 Will you require access to the Flight-line Restricted Area? Yes No Base Sponsor Yes No

#19 Industrial Maintenance Complex (IMC) Area? Yes No. #20 Have you ever been convicted of a felony? Yes [_ No

#21 Do you possess a Military ID card? Yes No

The above information is true and correct to the best of my knowledge. The Contractor or Designated Supervisor will sign/date below. The Contractor Sponsor (Base

Contracting Representative or Unit Representative) must also sign and include phone number to verify employment and sponsorship.

#22 Applicant’s Signature/Date: #23 Employment Supervisor/Superintendent:

Upon signing, I certify that I have read and understand item #20 on reverse side of worksheet. I have verified last five years of employment

Signature/Date:

Printed Name: _____________________________________________

Phone Number: _____________________________________________

#24 Sponsor Information:

Signature/Date: Printed Name:

Phone No: CAC DoD Control Number for DBIDS:

NOTE: INSTRUCTIONS FOR COMPLETING THIS WORKSHEET ARE ON THE REVERSE SIDE.

JB CHS Contract Security Worksheet for Base Access (Rev #5/29 October 2018) This worksheet is, For Official Use Only (FOUO) and must be protected under the Privacy Act of 1974, as amended. Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in criminal and/or civil penalties.”

Controlled Unclassified Information (CUI)

Joint Base Charleston (JB CHS) Worksheet for

Base Access Instructions

Guidelines for completing Worksheet

#1 & #2: COMPANY NAME: If the company is a (sub) also include the primary company’s name. (i.e. If the Sub is Coke, then the Primary is DECA)

#3 thru #9: Self Explanatory

#10 LOCATION OF WORK: Indicate where you will be working on JB CHS i.e., Air Base; Hunley Park; Flight line (Aircraft Parking Ramp) ; IMC (Industrial Maintenance Complex); WS East Side Ordanance;

North Side Ordanance; WHARF Alpha /Pier; Bravo/Pier; Charlie ; TC Dock; Traffic Control - ECP 19-TCI, Etc…….

NOTE: Badge issued for Contractor to work in Restricted Area and the IMC will have a “RED” back ground.

#11 thru #16: Self Explanatory

#17 A copy of a state driver’s license/state issued photo ID; Permanent resident card or Alien Registration Receipt Card (Form 1-551)

#18/19 INDUSTRIAL MAINTENANCE COMPLEX (IMC) and the FLIGHTLINE RESTRICTED AREA are (2) different areas: The IMC area requires you to enter through the access gates are doorways along the flight line. The controlled area consists of the flight line, buildings, and activities that support, maintain and secure the aircraft. Access is controlled through buildings along the perimeter and the vehicle and pedestrian gates. If working in the IMC area mark “YES” for issuance of a badge that allows you access to this area. Access to Flight-Line Restricted Area must be checked off by the base sponsor.

#20 When answering the FELONY question be honest! If the NCIC investigation produces a positive finding and you answered “NO”, your integrity will be questioned which will/can lead to denial of installation access. Any individual convicted of a felony to include but not limited to: murder, assault with intent to commit murder, rape, extortion, robbery, armed robbery, or any drug offense may be denied access to the installation. In addition, any individual currently on parole, probation or on the Sex Offender Registry will be denied access to the installation (Please Initial).

#21: Self explanatory

#22 & 23: Applicant signatures needed on #22 and Supervisor/Superintendent Signature needed on #23. NOTE* If applicant is the business owner then you will need to provide proof of ownership. EX: IRS 1040, Schedule "C" showing owners name and business name or City, County, or State Business License showing owners name and Company name.

#24: Sponsor Information

HOW LONG DOES IT TAKE

You do not get the worksheet back once it has been turned into the SFS VCC. The worksheet may take up to 72-hours to process and sometimes longer if discrepancies are found.

CONTRACTOR PASS PROCEDURES

(a) Once the contracting company hires the individual they will be required to fill out all information on the front of this worksheet, so they can obtain a badge/pass. It is the responsibility of the company requesting the contractor badge/pass to verify the validity of the employee’s driver license and legal status prior to the request being submitted. Any individual operating a vehicle on the installation must insure that it meets the minimum insurance requirements for the installation and the state of South Carolina. The issuance of a badge/pass is a privilege which can be withdrawn, and the individual can be barred from base for noncompliance with Joint Base Charleston policies and or USAF Directives. This badge/pass must be in the possession of the contractor at all times while on the installation. Contractor badge/pass must be visible on the employee at all times.

(b) When reporting to the Visitor Control Center to obtain an identification badge/pass, each employee will present a valid driver’s license or state issued picture identification.

(c) The badge/pass does not allow family members or friends to be sponsored on the installation at any time. In cases when family or friends must drive the contractor to the base, the drop off point is at the base entry gates. Employees are responsible for their own transportation to the job site.

(d) If the contractor terminates an employee the contractor will confiscate the employee pass and returned it to Contract Security Office in Bldg. 1953 (VCC).

(e) Upon completion or termination of the contract or expiration of the identification passes, the prime contractor shall ensure that all base identification passes issued to employees and subcontractor employees are returned to the issuing office, Security Forces in Bldg. 1953, Visitors Control Center (VCC).