8. JBAB Base Access Registration Form.xlsx
XLSX spreadsheet 17 KB Posted
- Attached to
- AAFES Underground Storage Tank Federal contract opportunity
- Solicitation number
- FA706024R0004
About this file
This document contains a federal contract solicitation and related registration form. The solicitation is for replacing underground storage tanks and associated components at an Army and Air Force Exchange Services gas station located at Joint Base Anacostia-Bolling in Washington, D.C. The scope of work includes replacing six under dispenser containment sumps, four 12,000-gallon underground fiberglass reinforced plastic gasoline storage tanks, associated piping, fittings, monitoring systems, and accessories. It also involves removing old tanks and sumps, excavating and backfilling trenches, testing and commissioning the new system, and coordinating with AAFES personnel. The acquisition is set aside for small businesses between $500,000 to $1,000,000, requires a 20% bid bond, and will result in a firm-fixed-price contract. The registration form is used to control physical access to the base and collect personal information for vetting and security purposes.
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Text version
Sheet1
| CUI JOINT BASE ANACOSTIA-BOLLING BASE ACCESS REGISTRATION FORM -- Solicitation: FA706024R0004, Atch #8 | |||||||
| PLEASE COMPLETE BOTH SIDES OF FORM | |||||||
| PRIVACY ACT STATEMENT: This information is protected under the Privacy Act of 1974. This form will be considered confidential when filled out. | |||||||
| AUTHORITY: 10 U.S.C., Department of Defense Manual (DoDM) 5200.08 Volume 3, AFMAN 31-101_Volume 3 I.A.C. & AFI 31-101 Integrated Defense | |||||||
| PURPOSE(S): To control physical access to Department of Defense facilities over which the 11th Security Forces Squadron has law enforcement jurisdiction. | |||||||
| ROUTINE USE(S): To designated contractors, Federal agencies, and foreign officials for the purpose of granting access to this DOD/USAF installation. | |||||||
| DISCLOSURE: | Providing registration information is voluntary. Failure to provide requested information may result in denial of access to this installation. | ||||||
| APPLICANT INFORMATION | |||||||
| 1. LAST NAME | 2. FIRST NAME | 3. MIDDLE NAME | 4. SUFFIX | ||||
| 5. GENDER (CIRCLE ONE) MALE OR FEMALE | 6. SOCIAL SECURITY NUMBER | 7. DATE OF BIRTH | 8. CITY/STATE OF BIRTH | 9. COUNTRY OF BIRTH | |||
| 10. U.S. CITIZEN (CIRCLE ONE) | YES | NO | 11. CITIZENSHIP, IF NOT U.S. (COUNTRY) |
12. WEIGHT (POUNDS) 13. HEIGHT (INCHES) 14. HAIR COLOR 15. EYE COLOR
| 16. HOME ADDRESS (INCLUDE CITY, STATE, ZIP CODE) | 17. CELL/HOME PHONE | ||||
| IDENTIFICATION DOCUMENTS | |||||
| 18. STATE ID/DRIVER'S LICENSE NUMBER | 19. STATE ISSUED | 20. DATE ISSUED | 21. DATE EXPIRES | ||
| 22. PASSPORT NUMBER | 23. COUNTRY ISSUED | 24. DATE ISSUED | 25. DATE EXPIRES | ||
| 26. GREEN CARD NUMBER | |||||
| 27. DATE ISSUED | 28. DATE EXPIRES | ||||
| 29. OTHER APPROVED IDENTIFICATION: | 30. DATE ISSUED | 31. DATE EXPIRES | |||
| FOR CONTRACTORS/SERVICE/VENDOR PROVIDERS: EMPLOYMENT ACTIVITY INFORMATION | |||||
| 32. EMPLOYER NAME AND ADDRESS (INCLUDE CITY/STATE/ZIP CODE) | 33. EMPLOYER PHONE NUMBER | ||||
| 34. SUPERVISOR NAME AND ADDRESS (INCLUDE CITY/STATE/ZIP CODE): | 35. SUPERVISOR PHONE NUMBER | ||||
| REQUIREMENT TO RETURN JBAB BASE ACCESS CREDENTIALS | |||||
| 36. I UNDERSTAND THAT I AM REQUIRED TO RETURN MY JBAB ISSUED BASE ACCESS CREDENTIAL TO THE JOINT VISITOR CONTROL CENTER WHEN IT EXPIRES OR IF MY EMPLOYMENT IS TERMINATED FOR ANY REASON. | INITIAL: ____________ | ||||
| AUTHORIZATION/RELEASE: | |||||
| 37. I hereby authorize the USAF/DoD and other authorized Federal agencies to obtain any information required from the Federal government and/or state agencies, including but not limited to , the Federal Bureau of Investigation (FBI), the Defense Security Service (DSS), & the U.S. Department of Homeland Security (DHS). I have been notified of USAF right to perform minimal vetting and fitness determination as a condition of access to DOD/USAF installations. I understand that I may request a record identifier; the source of the record and that I may obtain records from the state Law Enforcement Office as may be available to me under the law. I also understand that this information will be confidential. | |||||
| RELEASE (CONT.) AND CERTIFICATION | |||||
| 38. I release any individual, including records custodians, any component of the U.S. Government or the individual State Criminal History Repository supplying information, from all liability for damages that may result on account of compliance, or any attempts to to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representatives of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me. |
FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD RESULT IN FINES AND/OR IMPRISONMENT UP TO 5 YRS.
CAREFULLY REVIEW THE FORM BEFORE SIGNING TO ENSURE ALL REQUIRED BLOCKS ARE COMPLETED.
| I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE BY ME ON THIS FORM ARE | 1 Day Pass Request: 16 April 2024 from 7 AM to 2 PM |
| TRUE, COMPLETE AND CORRECT. | |
| 39. SPONSOR/AGENCY |
Trenton High/ 11 CONS
40. SPONSOR DoDI NUMBER
1504052970 41. SPONSOR PHONE NUMBER
937-422-1292
| CRIMINAL HISTORY BACKGROUND CHECK IS REQUIRED FOR BASE ACCESS |
| I have been advised of the required criminal history background check and give my consent by providing my signature in this block. |
DATE: ________________ SIGNATURE: ______________________________________
| CRIMINAL HISTORY | |||
| 42. WERE YOU EVER CONVICTED OF A FELONY? | YES | NO | INITIAL: ____________ |
| COMPLETED BY JOINT VISITOR CENTER PERSONNEL | ||||
| 43. INFORMATION VERIFIED BY | 44. DBIDS OPERATOR | 45. VALID REGISTRATION | 46. VEHICLE INSURANCE | |
| 47. BACKGROUND (OpenFox) PERFORMED BY | 48. RESULTS OF BACKGROUND CHECK | |||
| 49. VETTED DATE | 50. VETTED EXPIRATION DATE | |||
| 51. DURATION | PAPER | CARD | 52. PASS ISSUED/EXPIRATION DATES | |
| 53. APPROVED |
| Perimeter Access Control 27-Feb-2020 |
| FOR OFFICIAL USE ONLY |
&F
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