Attachment_JA-10.pdf

DARB 5 - APPLICATION FOR DOBBINS AIR RESERVE BASE CONTRACTOR /VENDOR ACCESS BADGE

Please note: DARB 5 must be completed by the Sponsor or Contracting Officer

EMPLOYER INFORMATION OF APPLICANT

1. NAME OF CONTRACTOR:

2. CONTRACTOR POINT OF CONTACT FULL NAME

3. DATE

4. PERMANENT MAILING ADDRESS:

5. CITY & STATE

6. ZIP CODE

7. FAX NUMBER: 8. WORK PHONE: 9. CELL PHONE: 10. (OPTIONAL) EMAIL:

11. CONTRACT NUMBER

12. CONTRACT PROJECTED START DATE

13. CONTRACT EXPIRATION DATE

APPLICANT INFORMATION

PRIVACY ACT STATEMENT: AUTHORITY: Title 5 USC, Section 301, Departmental Regulation. PRINCIPAL PURPOSE: To implement AFI 31-113, Installation Perimeter Access Control. ROUTINE USE: To request and records the issuance of Dobbins Air Reserve Base Contractor Credentials and record issuance of any identification credential when the use of another form has not been specified. DISCLOSURE: Information requested on the form is mandatory. Failure to provide any of the requested information will result in non-issuance of DARB identification credentials. I hereby acknowledge receipt of the credentials indicated by my signature on front and I am fully aware of my responsibilities pertaining to its use. I will promptly return all credentials when they are not needed for my assigned duties or upon request by proper authority.

1. LAST NAME: 2. FIRST NAME: 3. MI:

4. PERMANENT MAILING ADDRESS

NUMBER & STREET:

5. CITY & STATE:

6. ZIP CODE:

7. PERSONNEL CATEGORY:

PRIME: SUBCONTRACTOR: VENDOR/SVC WORKER

8. DOB (MANDATORY)

9. SSN (MANDATORY)

10. HOME PHONE: 11. WORK PHONE: 12. CELL PHONE:

13. PLACE OF BIRTH: 14. RESIDENT ALIEN# 15. (OPTIONAL) EMAIL:

16. CITIZENSHIP (CHECK ONE) U.S. CITIZEN ALIEN IMMIGRANT NON- U.S. NATIONAL

17. HAIR: 18. HEIGHT: 19. WEIGHT: 20. EYES:

21. ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S.? YES

NO

22. CONTRACTOR SIGNATURE

23. Have you ever been convicted of, or pled guilty or no contest to, a felony, misdemeanor, or any offense other than a minor traffic violation? Yes No

(Note: Conviction of a crime will not automatically disqualify you from further consideration for access).

If yes, in what country and state did it occur? Year:

Particulars regarding the convictions:

VEHICLE INFORMATION NEEDED IF APPLICANT WILL BE OPERATING A VEHICLE ON-BASE

1. LICENSE STATE: 2. VEHICLE MAKE:

3. LICENSE TAG #: 4. VEHICLE MODEL:

5. VIN #: (FOR SF USE ONLY) PROOF OF REGISTRATION VERIFIED: YES NO

6. VEHICLE COLOR: (FOR SF USE ONLY) PROOF OF INSURANCE VERIFIED: YES NO

7. VEHICLE YEAR: (FOR SF USE ONLY) DRIVER’S LICENSE VERIFIED: YES NO

8. SIGNATURE OF APPLICANT: 9. DATE:

SPONSORING AGENCY/CERTIFICATION OF CONTRACTING OFFICER/REQUESTING OFFICAL

I certify that in the event the above named individual is a non-US national, that the unescorted entry represents an exceptional requirement essential to the proper execution of the Wing’s mission. Such unescorted entry will not infringe upon the directives as outlined in DTM 09-012.

1. LAST NAME: Jacob 3. FIRST NAME: Kenneth 4. MI:

2. ORGANIZATION: 94CONF/LGC 5. WORK PHONE: 678-655-5745 WORK EMAIL: kenneth.jacob.1@us.af.mil

6. ACCESS DAYS (PLEASE CHECK ALL THAT APPLY): Su M T W TH F Sa 7. ACCESS TIMES: to

8. REGISTERED IN DBIDS YES NO 9. DD FORM 577, SIGNATURE CARD ON FILE WITH SF: YES NO

10. SIGNATURE: 11. DATE:

CONTRACTOR ACCESS BADGE ISSUE – Completed by Badge Issuing Official Only I certify that the individual whose name appears above has been the subject of a favorable criminal history search which meets the requirements of DTM 09-012, DoD 5200.08-R and DoDI 5200.08 for unescorted entry onto the installation.

INITIAL BADGE RENEWAL LOST/REISSUE

CARD NUMBER

CARD ISSUE DATE

CARD EXPIRATION DATE

BADGE ISUING OFFICAL (PRINT NAME)

SIGNATURE

DATE:

CRIMINAL HISTORY SEARCH FAVORABLE:

YES NO

REMARKS:

DARB FORM 5, REVISION4 2012MAY07