Atch_2 _NCIC_Screening.pdf

55 SFS CONTRACTOR/VENDOR NCIC SCREENING & PASS REQUEST SPREADSHEET

Personally Identifying Information (PII) being collected by this form is authorized for collection under provisions of 10 U.S.C. 8013, Secretary of the Air Force, DoD 5200.2R, DoD Personnel Security Program; AFI 33-202, Computer Security, Information will be maintained by local Security Forces Authority while access requirements exist. Information access is restricted to personnel responsible for contract administration, or otherwise needed in the performance of official DoD duties. Information will be properly disposed of when its required use has been concluded. Providing this information is voluntary; however, failure to provide all of the required data shown on the spreadsheet will result in denial of entry to the installation. This information is exempt from OMB licensing under provisions of AFI 33-324, Information Collections and Reports Management Program; Controlling Internal, Public, and Interagency Air Force Collections, paragraphs 3.16.11 and 3.16.16.3.

Offutt AFB Sponsoring Agency / Unit: (Filled in by base sponsor) Company Name:

Base Sponsor's Name: (Filled in by sponsoring agency) Company Address:

Base Sponsor's Phone #: (Work/Cell) (Filled in by base sponsor) Company Representative Name:

Request Date: (Filled in by base sponsor) Company Representative Phone Number:

Full Name Date of Birth SSAN Work Schedule U.S.

Citizen

Last

First, MI

Year

Month

Day

Drivers License/ID #

State

First

Last 6

Days

Hrs

Dates

(MMDDYYYY)

Yes / No

Contract#:

Contract Start/End Dates:

Sponsoring Unit Security Manager or Commander Signature Block/Signature