Attachment 5-Robins AFB Access Affidavit (Revised 31 Oct 2022) - Final_AdriaReimer.pdf

This document contains CONTROLLED UNCLASSIFIED INFORMATION (CUI) information which must be protected under the 32 CFR Part 2002.

(Updated 31 2 )

ROBINS AFB ACCESS AFFIDAVIT

Contractor Student Distinguished Visitor

SECTION I. Applicant Information (To be provided by Applicant)

Sex: ____M / ____F Name (Last, First, Middle): _______________________________________ State-ID/Driver’s License #: _______________________ Company Name: _________________________

SECTION II. Sponsor Information (To be completed by Badging Agent)

Badging Agent Name: _________________________________ Phone Number: __________________ Organization/Section: ________________________ Building # or Location for Intended Service: ________________________________________________ Purpose of Visit: ______________________________________________________________________ Expiration Date, Days of the Week, Hours of the Day Access is Needed:

Badging Agent Signature (Digital signature):

APPLICANT ATTESTATION:

I attest that I have been briefed by my employer and/or badging agent and understand the purpose of the criminal background check. I hereby give consent and authorize the 78 SFS to conduct any additional background screenings deemed necessary over the next 12 months, to include comparing/checking my fingerprints against local, state, and federal criminal databases. I voluntarily complete this form and shall provide the 78 SFS/S5P office my biometrics (one (1) front facing photo and a set of fingerprints), valid state-issued identification, proof of registration and insurance, and an unaltered social security card (or secondary form of identification) when requested for processing. I understand that by signing this application below, I acknowledge and understand Robins AFB “Disqualifying Factors” and will inform my badging agent if I am ever convicted of such. The information I have provided on this application is true, complete and correct to the best of my knowledge and is provided in good faith. I understand that knowingly and willfully making falsified statements can be punishable by fine, imprisonment, or both

IAW 18 U.S.C Section 1001.

Applicant Signature: _______________________________ Date: _____________ (Manually sign & date when instructed by 78 SFS/S5P)

FOR 78 SFS/S5P USE ONLY

Disposition of background check: Approved Denied

GCIC Clerk Signature: _______________________________ Date: _____________

DBIDS ID Number:

All individuals handling this information are required to protect it from unauthorized disclosure. Handling, storage, reproduction, and disposition of the attached document(s) must be in accordance with 32 CFR Part 2002 and applicable agency policy. Access to and dissemination of Controlled Unclassified Information shall be allowed as necessary and permissible to any individual(s), organization(s), or grouping(s) of users, provided such access or dissemination is consistent with or in furtherance of a Lawful

Government Purpose and in a manner consistent with applicable law, regulations, and Government-wide policies.