1.8_Background_Check_Form.pdf

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INSTALLATION ACCESS AFFIDAVIT

AUTHORITY: 5 U.S.C. 301 Departmental regulations; 10 U.S.C. 113, Secretary of Defense, Note at Pub.L. 106-65; 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 18 U.S.C. 1029, Fraud and related activity in connection with access devices; 18 U.S.C. 1030, Fraud and related activity in connection with computers; 40 U.S.C. Chapter 25, Information technology management; 50 U.S.C. Chapter 23, Internal Security; Pub.L. 106-398, Government Information Security Act; Pub.L. 100-235, Computer Security Act of 1987; Pub. L. 99-474, Computer Fraud and Abuse Act; E.O. 12958, Classified National Security Information as amended by E.O.13142 and 13292; E.O. 10450, Security Requirements for Government Employees; and E.O. 9397 (SSN).

PRINCIPAL PURPOSE: The records are maintained to support DoD physical security and information assurance programs and are used for identity verification purposes, to record personal property registered with the Department, and for producing facility management reports.

ROUTINE USE: DISCLOSURE WHEN REQUESTING INFORMATION ROUTINE USE: A record from a system of records maintained by this component may be disclosed as a routine use to a Federal, state, or local agency maintaining civil, criminal, or other relevant enforcement information or other pertinent information, such as current licenses, if necessary to obtain information relevant to a component decision concerning the hiring or retention of an employee, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant or other benefit.

LAW ENFORCEMENT ROUTINE USE: In the event that a system of records maintained by this component to carry out its functions indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and whether arising by general statute or by regulation, rule or order issued pursuant thereto, the relevant records in the system of records may be referred, as a routine use, to the appropriate agency, whether Federal, state, local, or foreign, charged with the responsibility of investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation or order issued pursuant thereto.

DISCLOSURE: Voluntary; however failure to provide complete and accurate information may result in you denied access to Luke Air Force Base.

SPONSOR/AGENCY:

PHONE #:

PURPOSE FOR PASS:

Contractor Non Recurring Long Term

LAST NAME:

FIRST NAME:

MI:

COMPANY:

DRIVER LICENSE NUMBER:

ISSUING STATE:

DATE OF BIRTH (mm/dd/yyyy):

BIRTHPLACE (City, State):

GENDER:

M F

CURRENT STREET ADDRESS

(No P.O. Boxes):

CITY:

STATE:

COUNTRY (If outside U.S.):

HAIR COLOR:

EYE COLOR:

HEIGHT:

WEIGHT:

U.S. CITIZEN:

YES

NO

PASSPORT OR USCIS FORM I-551 NUMBER AND EXPIRATION DATE (If Applicable):

Have you ever been arrested or convicted in any jurisdiction or country of a Misdemeanor or Felony crime (Excluding minor traffic citations)?

YES

NO

(If you answered yes, please provide a full explanation/year).

The information you provide will be verified through state and federal criminal history record checks:

I understand that willfully falsifying this application can result in barment and/or denied access to the installation.

APPROVAL/DENIAL DETERMINATION:

APPLICANT SIGNATURE:

DATE:

56 SFS APP. OFFICER:

DATE:

NOTE TO APPLICANT: Completion of this Installation Access Request Affidavit does not guarantee/validate entry authorization onto Luke Air Force Base. All Contractors must coordinate this affidavit through Sponsoring agency. Long term pass applicants coordinate through Sponsor. Submit this affidavit along with

(1) two forms of identification; One form must be from the DHS Form I-9, List B and the other form can be from either list A or C,

(2) a memorandum from the Sponsoring agency or Sponsor validating need for entry.

Completed package requires a minimum of 3 business days to process. Sponsoring agency or Sponsor will notify applicant when pass is ready for issue.

ALL INFORMATION WILL BE PROTECTED IAW PRIVACY ACT 1974, 5 U.S.C. § 552a

LUKE AFB FORM 338, 20131104

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