Attachment 6 - JB CHS 111.pdf

CUI (When Filled)

A-1. Name (Last, First, MI)

A-2. Drivers License or ID Card Number

A-3. Drivers License or ID Card State

A-4. Date of Birth A-5. US Citizen (Y/N. If N, list Citizenship Country)

A-6. SSN A-7. Phone

A-8a. Current Address:

Line 1 Street

A-8b. Current Address:

Line 2 Optional (e.g. Apt, Ste, Bldg)

A-8c. Current Address:

City, State

A-8d. Current Address:

ZIP Code

A-9. Signature (Wet or Digital)

A-10. Date

B-1. Company Name B-2. Company Phone

B-3. Days Access Needed (e.g. Monday-Friday)

B-4. Times (e.g. 0700-1700, 0000- 2359)

B-5. Access Start Date B-6. Access End Date

B-7. Locations (e.g. AB Bldg 5, WS Bldg 2)

B-8. Badge or Temp

C-1. Name (Last, First, MI)

C-2. Organization

C-3. Phone C-4. DOD ID

C-5. Signature (Wet or Digital)

C-6. Date

NOTE 1: COPY OF FRONT AND BACK OF DRIVERS LICENSE OR OTHER REAL ID COMPLIANT IDENTIFICATION MUST BE ATTACHED.

NOTE 2: CONTRACTOR PASS PROCEDURES ARE ON THE REVERSE SIDE.

JOINT BASE CHARLESTON (JB CHS) BASE ACCESS WORKSHEET

AUTHORTIY: Section 3101, Title 44 United States Code, AFI 33-332, 5 USC 552A PURPOSE: The purpose for requesting personnel information is to assist security personnel in developing records to document contractor employee suitability for access to Joint Base Charleston (JB CHS) to work under Air Force contracts. The Social Security Number (SSN) and Date of Birth (DOB) are necessary to identify the person of record. This information may be used to determine suitability of persons desiring access to JB CHS as well as for other lawful purposes including criminal background check and litigations.

INTENDED USE: All contractors and subcontractors working under Air Force contracts requiring regular and frequent access to JB CHS in performance of their official duties.

Refer to JBCHARLESTONI 31-106, Contractor Access Control Program, for further guidance.

DISCLOSURE: Disclosure of requested information is voluntary. However, failure to provide information may result in access privileges being refused or withdrawn.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.

SECTION A: APPLICANT INFORMATION

SECTION B: ACCESS INFORMATION

SECTION C: SPONSOR INFORMATION

JBCHARLESTON FORM 111 20250514

Supersedes: All Previous Versions Prescribed by: JBCHARLESTONI 31-106 CUI (When Filled)

JOINT BASE CHARLESTON (JB CHS) BASE ACCESS WORKSHEET

CONTRACTOR PASS PROCEDURES

7. Sponsor will be notified the status of application via e-mail from Contract Security. Sponsor is responsible for notifying prime contractor (contractor with which the government has a contract) of status.

8. Application processing may take up to 3 business days from drop-off of completed application.

9. Applicant must bring copy of Drivers License (if held), registration, and insurance for pickup of new pass. If Drivers License does not comply with Real ID standards, a second form of identification compliant with Real ID standards must also be provided.

10. The issuance of a badge/pass is a privilege that 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 possession of the contractor at all times while on the installation. Contractor badge/pass must be visible on the employee at all times.

11. If a contractor is terminated or upon completion of the job or the expiration of the identification card/pass, the Prime Contractor shall ensure that all base identification cards/passes issued to employees and subcontractor employees are returned to the issuing VCC.

12. If access is denied, applicant may obtain additional information regarding denial reason in-person at the VCC at which the application was processed. Applicant is entitled to appeal the results of the fitness determination. Further information regarding this process can be obtained from the VCC.

1. All applications may be typed or hand-written. See below for field specific instructions:

A-9: Application must be wet or digitally signed by applicant.

B-5: Requested start date may be up to 30 calendar days before or 30 calendar days after date of turn in; however, start date of pass will be date pass is issued.

B-6: Requested end date cannot exceed the day prior to requested start date in the following year, including leap years (e.g. 29 June 2024- 28 June 2024). Issued badge or pass end date may be before requested end date and is based on date of background check.

B-8: List "Badge" if access is required to the installation for 40 hours per work week for 90 calendar days or longer. List "Temp" if access is required less than 40 hours per work week or for a duration less than 90 calendar days. Temp Passes will be issued in 29-day increments.

C-5: Application must be wet or digitally signed by an appointed base sponsor.

2. Application must include a copy of the front and back of the applicant's Real ID Drivers License or other Real ID Compliant Identification.

3. 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 ensure that it meets the minimum insurance requirements, have a valid Driver's License and Vehicle Registration in the vehicle.

4. Turn in application to the VCC at which the pass will be picked up. Only appointed base sponsors are authorized to make pen and ink changes to an application at turn in. The following are the VCC addresses:

JB CHS Air Base VCC, 700 W Hill Blvd Bldg 1953, Joint Base Charleston, SC 29404 JB CHS Weapons Station VCC, 1650 Red Bank Rd Bldg 3, Joint Base Charleston, SC 29445

5. An NCIC background check will be conducted based on information provided in the application. Erroneous information may result in delays or rejection. It is the Applicant's responsibility to contact the applicable agency to correct the criteria resulting in denial.

6. Criminal history evaluation will be based on the following fitness determinations (see table below). A combination of convictions totaling to 50 or more points, or an offense identified as "DENIED", will result in access denial:

JBCHARLESTON FORM 111 20250514

Supersedes: All Previous Versions Prescribed by: JBCHARLESTONI 31-106

FRONT SIDE