MACC_55 SFS Contractor Vendor NCIC Screening Pass Request.pdf

PDF 348 KB Posted

Attached to
Offutt AFB Multiple Award Construction Contract (MACC) Federal contract opportunity
Solicitation number
FA4600-25-R-0002
Issued by
Department of the Air Force Air Combat Command

About this file

Written by GovTribe AI ·

This is a contractor/vendor NCIC screening and pass request spreadsheet form used by the 55th Security Forces Squadron at Offutt Air Force Base to process base access requests. The form collects personal identifying information (PII) for contractors and vendors requiring base access, including full name, date of birth, driver's license number, state, SSN, work schedule details, and U.S. citizenship status.

The form requires company information (name, address, representative details), contract information (number, start/end dates), and base sponsor details. The specific example shown is associated with solicitation FA460025R0002 and includes fields for work schedules (days/hours) and access dates. The form contains a privacy act statement explaining the authority for collecting the information under 10 U.S.C. 8013 and its restricted use for contract administration purposes. A signature block for the sponsoring unit security manager or commander is required for approval.

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Full Name U.S. Citizen Last, First, MI Year Month Day Drivers License/ID # State SSAN Days Hrs Dates (MMDDYYY) Yes / No

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.

55 SFS CONTRACTOR/VENDOR NCIC SCREENING & PASS REQUEST SPREADSHEET

Date of Birth

Offutt AFB Sponsoring Agency / Unit:

Base Sponsor's Name:

Base Sponsor's Phone #:

Request Date:

Work Schedule

Company Name:

Company Address:

Company Representative Name:

Company Representative Phone Number:

Contract#:

Contract Start/End Dates:

Sponsoring Unit Security Manager or Commander Signature Block/Signature

Offutt AFB Sponsoring Agency Unit:
Company Name:
Base Sponsors Name: Mic
Company Address:
Base Sponsors Phone:
Company Representative Name:
Request Date:
Last First MIRow1: Name
YearRow1: 19XX
MonthRow1: MAY
DayRow1: XX
Drivers LicenseID Row1: G59XXXXX
StateRow1: NE
SSANRow1: xxx-xx-xxxx
DaysRow1: Mon-Sat
HrsRow1: 0600-1800
Dates MMDDYYYRow1: 11152016-05252017
Yes NoRow1: Yes
Last First MIRow2:
YearRow2:
MonthRow2:
DayRow2:
Drivers LicenseID Row2:
StateRow2:
SSANRow2:
DaysRow2:
HrsRow2:
Dates MMDDYYYRow2:
Yes NoRow2:
Last First MIRow3:
YearRow3:
MonthRow3:
DayRow3:
Drivers LicenseID Row3:
StateRow3:
SSANRow3:
DaysRow3:
HrsRow3:
Dates MMDDYYYRow3:
Yes NoRow3:
Last First MIRow4:
YearRow4:
MonthRow4:
DayRow4:
Drivers LicenseID Row4:
StateRow4:
SSANRow4:
DaysRow4:
HrsRow4:
Dates MMDDYYYRow4:
Yes NoRow4:
Last First MIRow5:
YearRow5:
MonthRow5:
DayRow5:
Drivers LicenseID Row5:
StateRow5:
SSANRow5:
DaysRow5:
HrsRow5:
Dates MMDDYYYRow5:
Yes NoRow5:
Last First MIRow6:
YearRow6:
MonthRow6:
DayRow6:
Drivers LicenseID Row6:
StateRow6:
SSANRow6:
DaysRow6:
HrsRow6:
Dates MMDDYYYRow6:
Yes NoRow6:
Last First MIRow7:
YearRow7:
MonthRow7:
DayRow7:
Drivers LicenseID Row7:
StateRow7:
SSANRow7:
DaysRow7:
HrsRow7:
Dates MMDDYYYRow7:
Yes NoRow7:
Last First MIRow8:
YearRow8:
MonthRow8:
DayRow8:
Drivers LicenseID Row8:
StateRow8:
SSANRow8:
DaysRow8:
HrsRow8:
Dates MMDDYYYRow8:
Yes NoRow8:
Last First MIRow9:
YearRow9:
MonthRow9:
DayRow9:
Drivers LicenseID Row9:
StateRow9:
SSANRow9:
DaysRow9:
HrsRow9:
Dates MMDDYYYRow9:
Yes NoRow9:
Last First MIRow10:
YearRow10:
MonthRow10:
DayRow10:
Drivers LicenseID Row10:
StateRow10:
SSANRow10:
DaysRow10:
HrsRow10:
Dates MMDDYYYRow10:
Yes NoRow10:
Last First MIRow11:
YearRow11:
MonthRow11:
DayRow11:
Drivers LicenseID Row11:
StateRow11:
SSANRow11:
DaysRow11:
HrsRow11:
Dates MMDDYYYRow11:
Yes NoRow11:
Last First MIRow12:
YearRow12:
MonthRow12:
DayRow12:
Drivers LicenseID Row12:
StateRow12:
SSANRow12:
DaysRow12:
HrsRow12:
Dates MMDDYYYRow12:
Yes NoRow12:
Last First MIRow13:
YearRow13:
MonthRow13:
DayRow13:
Drivers LicenseID Row13:
StateRow13:
SSANRow13:
DaysRow13:
HrsRow13:
Dates MMDDYYYRow13:
Yes NoRow13:
Last First MIRow14:
YearRow14:
MonthRow14:
DayRow14:
Drivers LicenseID Row14:
StateRow14:
SSANRow14:
DaysRow14:
HrsRow14:
Dates MMDDYYYRow14:
Yes NoRow14:
Last First MIRow15:
YearRow15:
MonthRow15:
DayRow15:
Drivers LicenseID Row15:
StateRow15:
SSANRow15:
DaysRow15:
HrsRow15:
Dates MMDDYYYRow15:
Yes NoRow15:
Last First MIRow16:
YearRow16:
MonthRow16:
DayRow16:
Drivers LicenseID Row16:
StateRow16:
SSANRow16:
DaysRow16:
HrsRow16:
Dates MMDDYYYRow16:
Yes NoRow16:
Last First MIRow17:
YearRow17:
MonthRow17:
DayRow17:
Drivers LicenseID Row17:
StateRow17:
SSANRow17:
DaysRow17:
HrsRow17:
Dates MMDDYYYRow17:
Yes NoRow17:
Last First MIRow18:
YearRow18:
MonthRow18:
DayRow18:
Drivers LicenseID Row18:
StateRow18:
SSANRow18:
DaysRow18:
HrsRow18:
Dates MMDDYYYRow18:
Yes NoRow18:
Last First MIRow19:
YearRow19:
MonthRow19:
DayRow19:
Drivers LicenseID Row19:
StateRow19:
SSANRow19:
DaysRow19:
HrsRow19:
Dates MMDDYYYRow19:
Yes NoRow19:
Last First MIRow20:
YearRow20:
MonthRow20:
DayRow20:
Drivers LicenseID Row20:
StateRow20:
SSANRow20:
DaysRow20:
HrsRow20:
Dates MMDDYYYRow20:
Yes NoRow20:
Contract #: Sol: FA460025R0002
Contract End Date: N/A
Company Phone #:

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