Atch_3_-_NCIC_Data_Attachment.doc

DATE: ___________

MEMORANDUM FOR 55 SFS/S5A

FROM: _____________________________

(Companies Name)

SUBJECT: Contractor Employee Base Access Request - __________________________

(Contract Number)

1. Request a temporary base pass for ______________________________ (Employee’s Name) for a period of 30 days / 60 days / 90 days / 120 days / 1 year or ________ days beginning on _________ and expiring on ____________. The pass will be utilized for work on the following days and times (i.e. M-F, 8:00am to 5:00pm): ________________________________________________________________________.

2. This individual will be employed as a ______________________________ on contract __________________________ supporting _______________________ (AF unit/organization) and will perform the following duties: _______________________________________________________________

3. The following information is provided for granting entry onto Offutt AFB.

PERSONAL INFORMATION:

NAME:

SSN:

Address:

Date of Birth:

Driver’s License Number and State:

Phone Number:

3. I certify that if for any reason this individual’s authorization to enter the installation is terminated, I will retrieve the Visitor Pass and turn it in to the Visitor Center within 3 business days. I will brief the individual that the issued pass is issued for employment purposes only and is to be used exclusively during the hours of contract work requiring access to the base. I will brief the individual that the issued pass only allows access to the place of employment as required by the contract. A valid picture ID is required to be shown along with the Visitor Pass when entering the installation.

(Contractor POC printed name and signature)

(Duty Title and Phone Number)

PRIVACY ACT STATEMENT INFORMATION

Authority: 10 USC 8013, 44 USC 3101, and EO 9397

Purpose: to record personal information to determine whether a pass should be granted to allow installation access

Routine Uses: NONE

Disclosure is Voluntary: Failure to disclose the requested information will result in denial of entry to the installation

FA4600-13-R-0002 PMEAS II, Attachment 3, Pages 1