Site_Visit_Registration_Form.doc
DOC document 54 KB Posted
- Attached to
- Repair Outdoor Swimming Pool
- Solicitation number
- FA4661-16-R-0008
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Text version
CONTRACTOR SITE VISIT REGISTRATION FORM
INSTRUCTIONS: Please complete and return this form to A1C Lydia Simpkins/SSgt. Benjamin Brown by no later than 1400 Central Standard Time on 11 March 2016, if you wish to attend the site visit. Completed forms must be submitted to the following address. Completed forms must also be sent via e-mail to lydia.simpkins@us.af.mil AND benjamin.brown.16@us.af.mil.
Address:
7th Contracting Squadron
Attn: AIC Lydia Simpkins/SSgt. Benjamin Brown
381 Third Street
Dyess AFB TX 79607
Name & Address of Firm:
Point of Contact: ___________________________________
E-Mail Address: ____________________________________ Phone No.: _______________ Fax No.:_____________
Number of individuals to attend the contractor site visit: ____
CONTRACTOR/VENDOR LIST
Name of Prime Contractor:
Name of Sub Contractor:
| Company Address: |
| Company Address: |
| Phone number: |
| Phone Number: |
Contract For/or Type of Service:
Contract Number:
Start Date:
Completion Date:
| Base Sponsor/Unit: |
| 7 CONS/LGCA |
| POC: |
Duty Phone:
Vouch
Y or N
| Name: (Last, First Middle) |
| Local Address: |
| SSN:xxx-xx-xxxx |
| DOB: |
YY/MM/DD
| Driver LIC /State: |
| Resident Alien Card (If,AP)(MAN) |
N
N
N
N
N
N
N
N
N
The above information is correct to the best of my knowledge. The contractor or designated employee must sign, date and print name in signature block below.
Printed Name:
Signature:
Date:
SPONSOR INFORMATION ONLY:
| The above personnel have been checked against the base debarment listing. |
| YES |
NO
| Personnel will be working on the following days/times: |
| DAYS |
HOURS
By signing below I certify that I have a DD Form 557 (Signature Card) on file at Pass & Registration. (Ext 696-3088)
Printed Name:
Signature:
Date:
Privacy Act Statement
Information contained herein is personal and will not be disclosed to the public without permission of the individual, IAW AFI 37-312. DYESS FORM 173
File details come from the government source that posted it. Updated .