Attachment 5 - SF Form 74.pdf

Controlled Unclassified Information (CUI) This form is subject to the Privacy Act of 1974, 5 U.S.C.

319 SFS/DFSP SF Form 74, Version 2, 20230301

Section I. Personal Information Section

Last Name: First: Middle Initial: Date of Birth:

Home Address:

State ID #: State: Phone Number:

Social Security Number:

A) Have you ever been a citizen of another country?

B) Have you ever been employed by a foreign government, a foreign military organization, or a foreign-based corporation, association, or movement?

C) Have you ever been convicted of a crime, other than minor traffic violations?

D) Are there currently any charges and/or convictions pending against you?

If you answered “Yes” to any question above, please provide a brief summary:

In accordance with Grand Forks AFB Integrated Defense Plan, Tab A, Appendix 1, Annex C, IDP 2020, Security Forces members at the Commercial Vehicle Inspection Facility (CVIF) and Main Gate Visitor Control Center (VCC) will verify that all personnel entering the installation are authorized and will be subject to a thorough identity proofing, vetting, and fitness determination to control movement of personnel. In addition, the use of physical security measures/aides to search vehicles and parcels may be utilized prior to allowing access to the installation.

I have been advised on responsibilities, vouching authority, seat belt use, cell phone use, authorized areas, speed limits, and road conditions. By signing below, I affirm that the information provided is complete and accurate to the best of my knowledge.

Visitor Signature:

Section II. Organization Information Section

Organization Name: Address: Contract Number:

Phone Number: Prime Contractor:

(If Applicable)

Sub-Contractor:

(If Applicable)

Controlled Unclassified Information (CUI) This Form is subject to the Privacy Act of 1974, 5 U.S.C.

319 SFS/DFSP SF Form 74, Version 2, 20230301

Section III. Sponsor Information

By signing, you are indicating that you understand that you are responsible for the conduct of the visitor listed on Page 1. You also indicate that you have explained the rules regarding driving, prohibited areas, and personal conduct. Please note that all sponsors must be in possession of a Common Access Card (CAC) or pre-approved sponsor authority and be assigned to Grand Forks AFB.

Sponsor Name: Sponsor Signature: Phone Number:

Section IV. Base Access Permissions Section

Start Date:

Expiration Date:

Location(s) Bldg. #:

Military Housing or Base Wide

Day(s) Access:

Sun Mon Tue Wed Thu Fri Sat

Start Time:

End Time: or 24 Hrs. Sponsoring

Authority:

Authorized FPCON:

Additional Signature needed for

FPCON CHARLIE/DELTA

Signature/Date:

Section V. Approving Official (AO) Information

By signing below, you affirm that the information provided is complete and accurate to the best of your knowledge and that you authorize base access as outlined above. Please note, the only personnel authorized to sign are the owning commander, agency chief, or delegated personnel. In accordance with AFMAN 31- 101v3, ACC SUP, para. 3.26, you are confirming that the visitor has a valid purpose to enter the installation.

AO’s Organization: AO’s Name: AO’s Signature:

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Security Forces Fill Out Below

Background Check:

(Print Name)

Issue Date: Issued By:

Discrepancies:

Date:

Initials:

REF: