Base Access Request.docx

DEPARTMENT OF THE AIR FORCE

20th FIGHTER WING (ACC)

SHAW AIR FORCE BASE SOUTH CAROLINA

DATE: XX/XX/XXXX

MEMORANDUM FOR 20 SFS/S-5V:

(email to: BOTH Ms. Jacqueline Hernandez-Sears jacqueline.hernandez-sears.1@us.af.mil, TSgt Shelby Pontieri shelby.pontieri@us.af.mil , OR FAX 803-895-5337……. DUTY #:803-895-9085 or 803-895-9086/ VCC Email: udg_20sfs_vcc@us.af.mil)

This form MUST be sent by the sponsor listed from their government email and received at the email addresses/fax number listed above in the 20 SFS/S-5V section.

FROM: (The person requesting background check be conducted and squadron/unit)

SUBJECT: (i.e Contractor/Employee needing access to Shaw AFB)

WHO: (Company or Organization the Contractor/Employee will be working for)

WHAT FOR: (i.e Construction, New Hire, Job Interview, Meeting, New CAC or CAC Renewal, Work order etc.)

WHERE: (Location Contractor/Employee will be working at or needing access to)

If base wide give justification: (i.e Individual needs access to multiple buildings on base)

WHEN: (The exact day/dates and hours the individual will need access to the base (i.e. May 10, 2022, 0800-1700hrs or from May 10, 2022- May 10, 2023 Monday-Saturday, 0700-1900hrs)

SPONSOR: (The CAC holding individual responsible for the individual listed below and their organization)

CONTACT INFO: (Sponsor’s GOV email and PHONE NUMBER W/EXTENSION)

The information below is protected under Privacy Act 1974 and will only be used to process Criminal Background History Checks to grant or deny access to Shaw AFB. It is further understood that anyone abusing approved privileges could, at a minimum, lose said privilege and possibly face criminal charges.

EXAMPLE

Full Legal Name (Last, First MI) Date Of Birth (Year/Mo/Day) Social Security Number

ST-DL #

(REAL ID Y/N)

U.S.

Citizen (Y/N)

********IF UNDER THE AGE OF 18, PLEASE COMPLETE A SEPARATE WORK REQUEST.*********

I UNDERSTAND THAT AS THE SPONSOR I AM RESPONSIBLE FOR THE PERSON(S) LISTED ON THIS FORM, AND FOR ENSURING THE ABOVE NAME INDIVIDUAL(S) TURNS IN THE DBIDS PASS OR RETRIEVE THE PASS ONCE THE INDIVIDUAL(S) ARE TERMINATED, QUIT, OR NO LONGER REQUIRES ACCESS. IF I AM NOT ABLE TO RETRIEVE THE PASS, I WILL NOTIFY SECURITY FORCES TO HAVE THE INDIVIDUAL(S) PASS DEACTIVATED IN DBIDS.

DATE:

FROM:

SUBJECT:

WHO:

WHAT FOR:

WHERE:

If base wide give justification:

WHEN:

SPONSOR NAME:

DOD EDPI:

CONTACT INFO:

The information below is protected under Privacy Act 1974 and will only be used to process Criminal Background History Checks to grant or deny access to Shaw AFB. It is further understood that anyone abusing approved privileges could, at a minimum, lose said privilege and possibly face criminal charges.

Full Legal Name (Last, First MI) Date Of Birth (Year/Mo/Day) Social Security Number

ST-DL #

(REAL ID Y/N)

U.S.

Citizen (Y/N)

I UNDERSTAND THAT AS THE SPONSOR I AM RESPONSIBLE FOR THE PERSON(S) LISTED ON THIS FORM, AND FOR ENSURING THE ABOVE NAME INDIVIDUAL(S) TURNS IN THE DBIDS PASS OR RETRIEVE THE PASS ONCE THE INDIVIDUAL(S) ARE TERMINATED, QUIT, OR NO LONGER REQUIRES ACCESS. IF I AM NOT ABLE TO RETRIEVE THE PASS, I WILL NOTIFY SECURITY FORCES TO HAVE THE INDIVIDUAL(S) PASS DEACTIVATED IN DBIDS.

This form must be sent by the sponsor from their government email and received at the email addresses/fax number listed above in the 20 SFS/S-5V section.

CUI

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