Atch_7_Visitor_Access_Request_Form_and_Consent_Form.pdf

HOLLOMAN AFB

VISIT ACCESS REQUEST

(VAR-1)

For contracts awarded/administered by the 49th Contracting Squadron.

MEMORANDUM FOR 49 CONS/(XXX)

49 SFS/S5AV (49 SFS Pass and Registration)

IN TURN

FROM: (COMPANY NAME)

SUBJECT: Contractor Visit Access Request (VAR)

References:

a. Contract Number: (Required) Contract Title: (Required)

b. Contract Start Date: (Required) Contract End Date: (Required)

c. Contracting Office: 49th Contracting Squadron

d. Contracting Official/Phone: (Name of the Contracting Officer/Phone Number)

e. HAFB Point of Contact: (Contractor Program/Office Manager Information on Holloman)

Name_________________________________________ Telephone #____________________________________ E-mail address _________________________________

Request that a visitor pass be issued to the contractor(s) listed below. All employees will be briefed on and shall comply with HAFB security requirements. All employees have signed the government provided consent form authorizing the U.S. Government (United States Air Force) to conduct a background check to confirm their eligibility to be granted access to HAFB, NM.

(SFS USE

ONLY)

FULL NAME

SSN

DOB

POB

CITIZENSHIP/

PERM

RESIDENT/US

PASSPORT #

(IF

APPLICABLE)

PREVIOUS

TRACKING #

PRIVACY ACT STATEMENT

Authority: 10 U.S.C. 101 and E.O. 9397 Principal Purpose: For granting access to a military (Federal) installation.

Routine Use: Record access approval; use of SSN, DOB, POB &Citizenship is necessary to make positive identification of the individual and records.

Disclosure is Voluntary: Failure to provide the information could result in approval being denied.

ALL VARS MUST BE TYPED Current as of 17 Jan 12 1

HOLLOMAN AFB

VISIT ACCESS REQUEST

(VAR-1) cont.

Contractors denied unescorted entry as a result of their background check may be approved for escorted entry by the 49 SFS/CC. ONLY the site manager, foreman, superintendent (designated by asterisk on a VAR), or a contractor with a valid DoD Common Access Card (CAC) may escort employees approved for escorted entry. Contractor escort authority is limited to ONLY those employees approved for escorted entry. EXCEPTION: The site manager, foreman, superintendent, or a contractor with a valid DoD CAC may escort non-routine pickups and deliveries.

Pickup/delivery drivers will provide a bill of lading at the time of pass issuance; passes will not exceed six (6) hours.

Routine pickups and deliveries require the contractor add the driver(s) to a VAR to undergo the appropriate background check. All VARS must be typed and hand delivered to the Welcome Center.

Contractors shall report to the 49 SFS Welcome Center (bldg 1) with photo identification issued by a federal/state activity. Employees requesting to operate a company or privately owned vehicle on the installation shall provide a valid driver’s license, current vehicle registration, and proof of current vehicle insurance or car rental agreement.

All Foreign Nationals requesting access to HAFB (for official and unofficial visits) must provide three (3) valid forms of ID consisting of: A state issued drivers license/ID card, Social Security card, Resident alien card, Employment Authorization Document, or Passport/Birth certificate.

CONTRACTOR VISIT INFORMATION:

* Visitor passes will NOT exceed contract performance period or 1 year, whichever is less.

Period of visit: ___________________ to ___________________

Reason for visit: ________________________________________ (Brief description of work)

Visit location: ______________________________________ (Be specific; bldg/room #s, etc.)

Upon completion of visit and/or contractual requirements, all government issued credentials/passes shall be immediately returned to the 49 SFS Welcome Center Office.

Please direct any questions to me at (XXX) XXX-XXXX.

I certify the attached information is true and correct.

Signature of Company Official (Required) Date ________ (Required) Typed/Printed Name

Job Title/Company Name

I have reviewed and approved this visit access request.

Signature of 49 CONS official (Required) Date _________ (Required) Typed/Printed Name Duty Title

ALL VARS MUST BE TYPED Current as of 17 Jan 12 2