FA8650-19-S-1013-Atch9.pdf

SECURITY PROCEDURES SUPPLEMENT

The Security Procedures Supplement contains the explanation, direction and processes required by

Security Forces for Contractor access to Air Force installations. The following documents are included:

1. Notification of Contract Procedures

2. Example of Notification of Contract Letter

3. Example of Reissue of Base Identification Letter

4. Example of Contractor’s Additional Employees List Letter

5. Example of Termination of Employment Letter

6. Example of Appointment/Termination Record ‐ Signature Card (Wright‐Patterson AFB Form 1402)

7. Blank Appointment/Termination Record ‐ Signature Card (Wright‐Patterson AFB Form 1402)

8. Example of Application for WPAFB Identification Card (Wright‐Patterson AFB Form 1440)

9. Blank Application for WPAFB Identification Card (Wright‐Patterson AFB Form 1440)

Failure to follow the procedures and processes outlined in the Security Procedures Supplement will result in delays in Contractors gaining access to the base.

Attachment 9

AFARS 5352.242-9000

Supplement

DEPARTMENT OF THE AIR FORCE

HEADQUARTERS 88TH AIR BASE WING (AFMC)

WRIGHT-PATTERSON AIR FORCE BASE OHIO

MEMORANDOM FOR: CONTRACTORS AND CONTRACTING OFFICERS

FROM: 88 SFS/S3R (PASS AND REGISTRATION)

SUBJECT: NOTIFICATION OF CONTRACT PROCEDURES

NEW CONTRACT/OPTIONS/EXTENSION

Step 1 – Notification of Contract Letter

All contractors receiving WPAFB or US government-approved contracts, contract renewals or contract extensions must submit a “Notification of Contract” on company letter head signed by a company principal or designated agent, from the prime contractor and the base contracting officer containing the following information:

1. Installation specific contract number

2. Location of worksite(s) on base: Area(s) and Bldg#(s), the times & days of the week and the FPCON

Level (A,B or C) the contractors will need to have to access the installation

3. Minimum of one Authorized Signer a maximum of two - each of whom must be Principals and/or designated agents of the company - who will be able to sign for temporary passes for up to 30 days only.

4. Last names, First names, DOB, DL# and State the DL was issued (in alphabetical order) of all prime contractors and subcontractors performing work under the specific contract needing access to the installation for more than 30 days or for a second or more consecutive 30 day requests

5. The “Notification of Contract” or “Additional Employee List” letter (in alphabetical order) on company letterhead signed by a company principal or designated agent and the base contracting officer must be submitted to the 88SFS/S3R at least 48hrs prior (two (2) complete duty days) to the issuance of base identification or pass.

6. Only four (4) additions are authorized to the contract without producing a new Notification of Contract Letter

The Base Contracting Officer will approve this letter with original and official endorsement. The letter will then be hand carried to 88 SFS/S3R. “Notification of contracts”, “Additional Employee List” or “Notification of Cement, Concrete & Asphalt Deliveries” will not be accepted without original, “wet” signatures. No faxes, copies or scans of any type will be accepted (Blue ink maybe used for signatures).

Step 2 – WPAFB Form 1440 Request for Base Identification Contractors must provide Pass & Registration with a correct and completed WPAFB Form 1440 certified by the Certified Requesting Official with the following information and will not be accepted without original, “wet” signatures:

1. Address to 88 SFS/S3R Wright-Patterson AFB, OH 45433

2. Prime contractor company name, address and phone number

3. Subcontractor’s name, address and phone number (if applicable)

4. Complete all personal information to include full SSN or as stated on state identification or DoD ID

Number.

5. Installation specific contract number the individual is working on

6. The Certified Requesting Official will enter a contract number, card expiration date (no longer than three years), Days, Times, Area(s) and FPCON level. The form must be correct and fully completed prior to arriving at Pass & Registration or will result in denial of credential issuance.

7. The WPAFB form 1440 will only be valid for 30 days from the date signed by the Certified Requesting Official. No faxes, copies or scans allowed (Blue ink maybe used for signatures).

Important! The Certifying Requesting Official must have a WPAFB Form 1402 (Signature Card) with an original “wet” signature on file with 88 SFS/S3R Pass& Registration. The Certifying Requesting Official will either be a US Government Contracting Officer, US Government official (DoD Civilian or Active Duty Military) or a US Government Contracting Officer’s representative overseeing the contract. These are the only individuals able to sign the WPAFB Form 1440 and the individuals who sign the WPAFB Form 1440 will be responsible for all actions of the contractors that they sign for while working on WPAFB. Please call Pass and Registration ahead of time to check for policy/regulation changes or updates. The phone number to Pass and Registration is 257-3955. No faxes, scans or copies allowed.

Attachment 9

COMPANY LETTER HEAD

To: 88 SFS/S3R (Pass and Registration Office) 4185 Logistics Avenue Wright-Patterson AFB, OH 45433-5737

Subject: Notification of Contract Reference: Base Specific Contract # XXXXXX-XX-X-XXXX

Company name has been awarded contract # XXXXXX-XX-X-XXXX. The contract period of performance is XX/XXX/.XXXX through XX/XX/XXXX excluding options years. The operating duty days of the week will be from XXX through XXX and operating duty times will be from XXXX hrs through XXXX hrs. The Contractors shall perform all support and services under this contract at location(s) (Bldg. #s) in Area(s) XXXXX. The FPCON Level on which the contractors will perform work on the installation will be XXXXX

The following employees (in alphabetical order) will be working on-site in support of the referenced order:

Employee A (Last Name, First Name, MI., DOB, DL# and State) Employee B (Last Name, First Name, MI., DOB, DL# and State) Employee C(Last Name, First Name, MI., DOB, DL# and State) Employee D (independent consultant for primary contractor) (Last Name, First Name, MI., DOB, DL# and State)

Subcontractor’s employees (in alphabetical order) of Company XXXX

Employee A (Last Name, First Name, MI., DOB, DL# and State) Employee B (Last Name, First Name, MI., DOB, DL# and State) Employee C (Last Name, First Name, MI., DOB, DL# and State) Employee D (independent consultant for subcontractor) (Last Name, First Name, MI., DOB, DL# and State)

The following employee(s) will be point of contact and will be the “Authorized Signer(s)” who must be principals and/or agents from the PRIME CONTRACTOR ONLY (for contract # XXXXXX-XX-X-XXXX). “Authorized Signers” will ensure all employees of the prime contractor, sub-contractor and all day labors working on this contract will be citizens of the United States or have the USCIS issued Permanent Resident Card (Form I-551) with them at all times. If compliance is not met the “Authorized Signer” will lose their status.

Employee A (Last Name, First Name, MI., DOB, DL# and State) sig_______________________ Employee B (Last Name, First Name, MI., DOB, DL# and State) sig._______________________

Please contact me with any questions at (XXX) XXX-XXXX.

Sincerely, sig. __________________________ sig.__________________________________

John Doe (must be principal or agent) (Print or stamp) Contracting Officer Signature Block Company name / Title, Phone Number Squadron / Office Symbol, Phone Number

Attachment 9

Wright-Patterson AFB, OH 45433-5737

Subject: Reissue of Base Identification Reference: Base Specific Contract # XXXXXX-XX-X-XXXX

The following employee has misplaced / lost their identification or their identification is unserviceable and requires a replacement. If the original identification is found, it will be returned to 88 SFS/S5SP office with appropriate paperwork for destruction.

The following employees (in alphabetical order) will be working on-site in support of the referenced order:

Employee A (Last Name, First Name, MI., DOB, DL# and State) Employee B (Last Name, First Name, MI., DOB, DL# and State) Employee C(Last Name, First Name, MI., DOB, DL# and State) Employee D (independent consultant for primary contractor) (Last Name, First Name, MI., DOB, DL# and State)

Subcontractor’s employees (in alphabetical order) of Company XXX

Employee A (Last Name, First Name, MI., DOB, DL# and State) Employee B (Last Name, First Name, MI., DOB, DL# and State) Employee C (Last Name, First Name, MI., DOB, DL# and State) Employee D (independent consultant for subcontractor) (Last Name, First Name, MI., DOB, DL# and State)

This letter along with a new, completed WPAFB Form 1440 will accompany the individual who misplaced/lost their base identification card for replacement.

Please contact me with any questions at (XXX) XXX-XXXX

John Doe (must be principal or agent) Company name and title Sig._________________________

John Q. Smith WPAFB Contracting Officer Sig.__________________________

Attachment 9

Wright-Patterson AFB, OH 45433-5737

Subject: Contractor’s Additional Employees List

The following employees (in alphabetical order) will be working on-site in support of the referenced order:

Employee A (Last Name, First Name, MI., DOB, DL# and State) Employee B (Last Name, First Name, MI., DOB, DL# and State) Employee C(Last Name, First Name, MI., DOB, DL# and State) Employee D (independent consultant for primary contractor) (Last Name, First Name, MI., DOB, DL# and State)

Subcontractor’s employees (in alphabetical order) of Company XXX

Employee A (Last Name, First Name, MI., DOB, DL# and State) Employee B (Last Name, First Name, MI., DOB, DL# and State) Employee C (Last Name, First Name, MI., DOB, DL# and State) Employee D (independent consultant for subcontractor) (Last Name, First Name, MI., DOB, DL# and State)

The PRIME CONTRACTOR will ensure all employees of the prime contractor, sub-contractor and all day labors working on this contract will be citizens of the United States or have the USCIS issued Permanent Resident Card (Form I-551) with them at all times.

Contracting Officer Signature Block Squadron / Office Symbol, Phone Number

Attachment 9

Wright-Patterson AFB, OH 45433-5737

Subject: Termination of Employment

The following identification and vehicle passes / decals are being returned for destruction due to termination of employment.

referenced order:

Employee A (Last Name, First Name, MI., DOB, DL# and State)

Employee B ID card /Visitor’s Pass# XXXXXXXX (Employee’s Name) is retired government worker whose vehicle is not registered under this contract

Subcontractor’s employees of Company XXXXXX referenced order:

Employee A (Last Name, First Name, MI., DOB, DL# and State)

Employee B ID card/Visitor’s Pass #XXXXXXXX (Employee’s Name) is retired government worker whose vehicle is not registered under this contract

Contracting Officer Signature Block Squadron / Office Symbol, Phone Number

Attachment 9

AUTHORITY: Powers and duties, delegated by 10 U.S.C, 8013, Secretary of the Air Force and E.O. 9397 (SSN).

PRINCIPAL PURPOSES: To maintain a record of certifying and accountable officers' appointments, and termination of those appointments. The information will also be used for identification purposes associated with certification of documents. Badge records are used to record building/area entry credential information including information on the loss of theft of these credentials. Used by the security police for issuing ID cards and these restricted or controlled area badges which authorize entry into certain areas. Some organizations may routinely keep copies of the above documentation in order to maintain control over persons authorized entry into certain areas. Accountability documents are used to insure proper control over the various forms utilized in these functions.

ROUTINE USE(S): In addition to those disclosure generally permitted under 5 U.S.C., 55a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C., 552a(b)(3) as follows: The Blanket Routine Uses published at the beginning of the Air Force's compilation of systems of records notices apply.

DISCLOSURE: Voluntary, however, failure to provide the requested information my preclude appointment.

CERTIFYING REQUESTING OFFICIAL FOR THE WPAFB FORM 1440

COMMMANDER/APPOINTING AUTHORITY

PRIVACY ACT STATEMENT

Read Privacy Act Statement and Instructions before completing form.

CLAUSE, SANTA A.

JOHN A. SMITH 25AW/XP

APPOINTMENT/TERMINATION RECORD - SIGNATURE CARD

SECTION I

1. NAME 3. ORGANIZATION

6. NAME 7. TITLE 8. ORGANIZATION

WRIGHT-PATTERSONAFB FORM 1402, 20070329

00001225

4. DATE 5. SIGNATURE(YYYYMMDD)

(First, MI, Last)

(First, MI, Last)

(include zip code)

APPOINTEESECTION II

123 FIRST STREET NPAFB, NORTH POLE 20080408

BOTH

10. ADDRESS

9. PHONE (include Area Code)

(Specify)

(YYYYMMDD)

(937) 000-0000

11. EFFECTIVE DATE OF APPOINTMENT

CONT. OFFICER

(check one)12. POSITION APPOINTED

CERTIFYING OFFICER ACCOUNTABLE OFFICIAL OTHER

2. TITLE

COMMANDER 25AW/CC

(LEAVE BLANK)

13. YOU ARE HEREBY APPOINTED TO SERVE THE CAPACITY/POSITION SHOWN ABOVE. YOUR RESPONSIBILITIES WILL INCLUDE?

19. NAME OF COMMANDER/APPOINTING AUTHORITY

TERMINATION OF APPOINTMENTSECTION IV

I ACKNOWLEDGE AND ACCEPT THE POSITION AND RESPONSIBILITIES DEFINED ABOVE. I CERTIFY THAT MY OFFICIAL SIGNATURE IS SHOWN IN THE

BOX BELOW.

ACKNOWLEDGEMENT OF APPOINTMENTSECTION III

14. YOU ARE ADVISED TO REVIEW AND ADHERE TO THE FOLLOWING REGULATION(S) NEEDED TO ADEQUATELY PERFORM THE DUTIES TO WHICH YOU

HAVE BEEN ASSIGNED.

JOHN A. SMITH

15. NAME(First, MI, Last) 16. SIGNATURE

(YYYYMMDD)17. EFFECTIVE DATE 18. APPOINTEE INITIALS

7. TITLE 21. SIGNATURE

THE APPOINTMENT OF THE INDIVIDUAL NAMED ABOVE IS REVOKED

Attachment 9

AUTHORITY: Powers and duties, delegated by 10 U.S.C, 8013, Secretary of the Air Force and E.O. 9397 (SSN).

PRINCIPAL PURPOSES: To maintain a record of certifying and accountable officers' appointments, and termination of those appointments. The information will also be used for identification purposes associated with certification of documents. Badge records are used to record building/area entry credential information including information on the loss of theft of these credentials. Used by the security police for issuing ID cards and these restricted or controlled area badges which authorize entry into certain areas. Some organizations may routinely keep copies of the above documentation in order to maintain control over persons authorized entry into certain areas. Accountability documents are used to insure proper control over the various forms utilized in these functions.

ROUTINE USE(S): In addition to those disclosure generally permitted under 5 U.S.C., 55a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C., 552a(b)(3) as follows: The Blanket Routine Uses published at the beginning of the Air Force's compilation of systems of records notices apply.

DISCLOSURE: Voluntary, however, failure to provide the requested information my preclude appointment.

COMMMANDER/APPOINTING AUTHORITY

PRIVACY ACT STATEMENT

Read Privacy Act Statement and Instructions Before Completing Form.

APPOINTMENT/TERMINATION RECORD - SIGNATURE CARD

SECTION I

1. NAME 3. ORGANIZATION

6. NAME 7. TITLE 8. ORGANIZATION

WRIGHTPATTERSONAFB FORM 1402, 20121017

4. DATE5. SIGNATURE (YYYYMMDD)

(First, MI, Last)

(First, MI, Last)

(include zip code)

APPOINTEESECTION II

10. ADDRESS

9. PHONE (include Area Code)

(Specify)

(YYYYMMDD)11. EFFECTIVE DATE OF APPOINTMENT

(check one)12. POSITION APPOINTED

CERTIFYING OFFICER ACCOUNTABLE OFFICIAL OTHER

2. TITLE

13. YOU ARE HEREBY APPOINTED TO SERVE THE CAPACITY/POSITION SHOWN ABOVE. YOUR RESPONSIBILITIES WILL INCLUDE?

19. NAME OF COMMANDER/APPOINTING AUTHORITY

TERMINATION OF APPOINTMENTSECTION IV

I ACKNOWLEDGE AND ACCEPT THE POSITION AND RESPONSIBILITIES DEFINED ABOVE. I CERTIFY THAT MY OFFICIAL SIGNATURE IS SHOWN IN THE BOX

BELOW.

ACKNOWLEDGEMENT OF APPOINTMENTSECTION III

14. YOU ARE ADVISED TO REVIEW AND ADHERE TO THE FOLLOWING REGULATION(S) NEEDED TO ADEQUATELY PERFORM THE DUTIES TO WHICH YOU

HAVE BEEN ASSIGNED.

15. NAME(First, MI, Last) 16. SIGNATURE

(YYYYMMDD)17. EFFECTIVE DATE 18. APPOINTEE INITIALS

7. TITLE 21. SIGNATURE

THE APPOINTMENT OF THE INDIVIDUAL NAMED ABOVE IS REVOKED

FOR OFFICIAL USE ONLY WHEN FILLED IN

FOR OFFICIAL USE ONLY WHEN FILLED IN

PREVIOUS EDITION IS OBSOLETE

Click to sign

Click to sign

Click to sign

Attachment 9

INSTRUCTIONS FOR COMPLETING�

APPOINTMENT/TERMINATION RECORD - SIGNATURE CARD

THIS FORM MAY BE USED TO:

NOTE: COMPLETING THIS SECTION WILL TERMINATE THE ORIGINAL APPOINTMENT AS OF THE EFFECTIVE DATE. IF PARTIAL AUTHORITY IS TO BE RETAINED, A NEW WPAFB 1402 MUST BE COMPLETED. CHECK THE BOX PROVIDED TO INDICATE THE APPOINTMENT IS

BEING REVOKED.

SECTION I

1.

WRIGHTPATTERSONAFB FORM 1402, 20121017

APPOINT CERTIFYING OFFICERS. CERTIFYING OFFICERS ARE THOSE INDIVIDUALS, MILITARY OR CIVILIAN, DESIGNATED TO ATTEST TO THE CORRECTNESS OF STATEMENTS, FACTS, AND INFORMATION APPEARING ON IDENTIFICATION CARDS AND THESE

RESTRICTED OR CONTROLLED AREA BADGES.

2.

APPOINT ACCOUNTABLE OFFICIALS. ACCOUNTABLE OFFICIALS ARE THOSE INDIVIDUALS , MILITARY OR CIVILIAN, WHO ARE DESIGNED IN WRITING AND ARE NOT OTHERWISE ACCOUNTABLE UNDER APPLICABLE LAW, WHO PROVIDE SOURCE INFORMATION, DATA OR SERVICE TO A CERTIFYING OFFICER IN SUPPORT OF ISSUING PROCESS.

1. ENTER THE NAME OF THE COMMANDER/APPOINTING AUTHORITY

2. ENTER THE COMMANDER/APPOINTING AUTHORITY'S TITLE

3. ENTER THE NAME OF THE COMMANDER/APPOINTING AUTHORITY'S ORGANIZATION LOCATION

4. ENTER THE DATE THE FORM IS COMPLETED

5.

8.-10.

THE COMMANDER/APPOINTING MUST PLACE HIS OR HER LEGAL SIGNATURE IN THE BLOCK PROVIDED

SECTION II

ENTER THE NAME, COMPLETE ADDRESS, AND PHONE NUMBER OF THE ORGANIZATION ACTIVITY TO WHICH APPOINTED.

6. ENTER THE APPOINTEE'S NAME

7. ENTER THE APPOINTEE'S TITLE

11. ENTER THE DATE THE APPOINTMENT IS TO BE EFFECTIVE

12. CHECK THE APPROPRIATE BOX INDICATING THE PURPOSE FOR THE APPOINTMENT

13. DESCRIBE IN DETAIL THE DUTIES THE APPOINTEE WILL BE REQUIRED TO PERFORM, TO INCLUDE TYPES OF CREDENTIALS, FOR

WHICH AUTHORIZED, AND ANY OTHER PERTINENT INFORMATION

14. LIST ALL REGULATIONS THE APPOINTEE MUST REVIEW AND FOLLOW IN ORDER TO ADEQUATELY FULFILL THE REQUIREMENTS OF

THE APPOINTMENT

SECTION III

15.-16. THE APPOINTEE SHALL PRINT (OR TYPE) HIS OR HER NAME AND ENTER HIS OR HER LEGAL SIGNATURE IN THE SPACES PROVIDED

SECTION IV

17. ENTER THE DATE THE TERMINATION IS EFFECTIVE

18. THE APPOINTEE WILL INITIAL IN THE SPACE PROVIDED ACKNOWLEDGING REVOCATION OF THE APPOINTMENT

20.-22. THE COMMANDER/APPOINTING AUTHORITY MUST PLACE HIS OR HER NAME, TITLE AND LEGAL SIGNATURE IN THE SPACES

PROVIDED

Attachment 9

WRIGHTPATTERSONAFB FORM 1440, 20121024

APPLICATION FOR WPAFB IDENTIFICATION CARD

(This Form Is Subject to the Privacy Act of 1974)

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 8013

PRINCIPAL PURPOSE: Used by the security police for issuing ID cards and these restricted or controlled area badges which authorize entry into certain areas. Some organizations may routinely keep copies of the above documentation in order to maintain control over persons authorized entry into certain areas. Accountability documents are used to insure proper control over the various forms utilized in these functions.

ROUTINE USE: To request and record the issuance of computer generated WPAFB Contractor/Visitor Identification Card and to request and record issuance of any identification credential when the use of another form has not been specified.

DISCLOSURE: Information requested on the form is voluntary. Failure to provide any of the requested information will result in non-issuance of identification credentials.

I hereby acknowledge receipt of the credentials indicated by my signature below and am fully aware of my responsibilities pertaining to their use.

I will promptly return all credentials when they are not needed for my assigned duties or upon requested by proper authority.

NOTICE: While on this installation all personnel and the property under their control are subject to search. Controlled radioactive material being brought onto an AFMC installation must first be approved by the monitor for nuclear safety.

TO FROM (Business Address or Orgn/ Symbol/Sponsor/ of Prime Contractor)

LOCAL BUSINESS ADDRESS OR SUB

-CONTRACTOR/PHONE

88 SFS/S3R (Pass & Registration) Wright-Patterson AFB, OH 45433

" PRIME CONTRACTOR " " SUB-CONTRACTOR "

NAME RACE SSN OR DoD ID NUMBER

MR. MRS. MS

N/ADOE, JOHN A.

DRIVERS LICENSE/STATE ID NUMBER DATE OF BIRTH CITIZEN (Country)

ABC12345 00 / MMM / 0000 US (OR OTHER)

HAIR HEIGHT

OFFICIAL CONTRACTOR VOLUNTEER

WEIGHT EYES

BROWN 72" 200 lbs. BROWN

HOME ADDRESS PHONE

1234 FIRST STREET DAYTON, OHIO 45433 (000) 000-0000

CONTRACT NUMBER MUST HAVE CONTRACT NUMBER

CARD EXPIRATION MUST HAVE SPECIFIC EXP. DATE

ISSUE DATE AREAS AUTHORIZED BY CONTRACT

(LEAVE BLANK)

SIGNATURE OF ISSUING OFFICIALSIGNATURE OF RECIPIENT

CERTIFICATE OF REQUESTING OFFICIAL

********************WARNING NOTICE********************

********************WARNING NOTICE********************

BY PLACING YOUR SIGNATURE ABOVE YOU AGREE:

1. ALL INFORMATION OBTAINED ON THIS FORM WILL BE USED TO CONDUCT A CRIMINAL BACKGROUND CHECK PRIOR TO ISSUANCE OF IDENTIFICATION. ____ (Initials)

2. UPON TERMINATION, REASSIGNMENT, DISCHARGE, OR SEPARATION FOR ANY REASON THE ABOVE APPLICANT AGREES TO RETURN AND SURRENDER THE IDENTIFICATION CARD OR AIR FORCE FORM 75, TEMPORARY VISITOR PASS TO THE 88TH SECURITY FORCES SQUADRON PASS AND REGISTRATION. ____ (Initials)

I certify that the applicant has an official/authorized need for the credential requested and has been briefed on its proper use.

NAME/TITLE

JOHN Q. SMITH, (TITLE) (Authorized Gov. Signatory)

BUSINESS ADDRESS OR ORGANIZATION/SYMBOL

AFRL/PKO

SIGNATURE PHONE DATE

(000) 000-0000 00 / MM / 0000

STATE

STATE

UNOFFICIAL/VENDOR

CARD NUMBER

(LEAVE BLANK)

DAYS AUTHORIZED (Check appropriate)

MON TUE WED THUR FRI SAT SUN

AUTHORIZED TIMES FPCON

0000hrs - 0000hrs TYPE ALLOWED

FOR OFFICIAL USE ONLY WHEN FILLED IN

FOR OFFICIAL USE ONLY WHEN FILLED IN

PREVIOUS EDITION IS OBSOLETE

AREA B

AREA A

000-00-0000

Attachment 9

WRIGHTPATTERSONAFB FORM 1440, 20121024

APPLICATION FOR WPAFB IDENTIFICATION CARD

(This Form Is Subject to the Privacy Act of 1974)

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 8013

PRINCIPAL PURPOSE: Used by the security police for issuing ID cards and these restricted or controlled area badges which authorize entry into certain areas. Some organizations may routinely keep copies of the above documentation in order to maintain control over persons authorized entry into certain areas. Accountability documents are used to insure proper control over the various forms utilized in these functions.

ROUTINE USE: To request and record the issuance of computer generated WPAFB Contractor/Visitor Identification Card and to request and record issuance of any identification credential when the use of another form has not been specified.

DISCLOSURE: Information requested on the form is voluntary. Failure to provide any of the requested information will result in non-issuance of identification credentials.

I hereby acknowledge receipt of the credentials indicated by my signature below and am fully aware of my responsibilities pertaining to their use.

I will promptly return all credentials when they are not needed for my assigned duties or upon requested by proper authority.

NOTICE: While on this installation all personnel and the property under their control are subject to search. Controlled radioactive material being brought onto an AFMC installation must first be approved by the monitor for nuclear safety.

TO FROM (Business Address or Orgn/ Symbol/Sponsor/ of Prime Contractor)

LOCAL BUSINESS ADDRESS OR SUB

-CONTRACTOR/PHONE

NAME RACE SSN OR DoD ID NUMBER

MR. MRS. MS

DRIVERS LICENSE/STATE ID NUMBER DATE OF BIRTH CITIZEN (Country)

HAIR HEIGHT

OFFICIAL CONTRACTOR VOLUNTEER

WEIGHT EYES

HOME ADDRESS PHONE

CONTRACT NUMBER

CARD EXPIRATION

ISSUE DATE AREAS AUTHORIZED BY CONTRACT

SIGNATURE OF ISSUING OFFICIALSIGNATURE OF RECIPIENT

CERTIFICATE OF REQUESTING OFFICIAL

********************WARNING NOTICE********************

********************WARNING NOTICE********************

BY PLACING YOUR SIGNATURE ABOVE YOU AGREE:

1. ALL INFORMATION OBTAINED ON THIS FORM WILL BE USED TO CONDUCT A CRIMINAL BACKGROUND CHECK PRIOR TO ISSUANCE OF IDENTIFICATION. ____ (Initials)

2. UPON TERMINATION, REASSIGNMENT, DISCHARGE, OR SEPARATION FOR ANY REASON THE ABOVE APPLICANT AGREES TO RETURN AND SURRENDER THE IDENTIFICATION CARD OR AIR FORCE FORM 75, TEMPORARY VISITOR PASS TO THE 88TH SECURITY FORCES SQUADRON PASS AND REGISTRATION. ____ (Initials)

I certify that the applicant has an official/authorized need for the credential requested and has been briefed on its proper use.

NAME/TITLE BUSINESS ADDRESS OR ORGANIZATION/SYMBOL

SIGNATURE PHONE DATE

STATE

UNOFFICIAL/VENDOR

CARD NUMBER

DAYS AUTHORIZED (Check appropriate)

MON TUE WED THUR FRI SAT SUN

AUTHORIZED TIMES FPCON

FOR OFFICIAL USE ONLY WHEN FILLED IN

FOR OFFICIAL USE ONLY WHEN FILLED IN

PREVIOUS EDITION IS OBSOLETE

AREA B

AREA A

Attachment 9

INSTRUCTIONS FOR COMPLETING

APPOINTMENT/TERMINATION RECORD - SIGNATURE CARD

THIS FORM MAY BE USED TO:

NOTE: COMPLETING THIS SECTION WILL TERMINATE THE ORIGINAL APPOINTMENT AS OF THE EFFECTIVE DATE. IF PARTIAL AUTHORITY IS TO BE RETAINED, A NEW WPAFB 1402 MUST BE COMPLETED. CHECK THE BOX PROVIDED TO INDICATE THE APPOINTMENT IS BEING

REVOKED.

SECTION I

1.

WRIGHT-PATTERSONAFB FORM 1402, 20070329

APPOINT CERTIFYING OFFICERS. CERTIFYING OFFICERS ARE THOSE INDIVIDUALS, MILITARY OR CIVILIAN, DESIGNATED TO ATTEST TO THE CORRECTNESS OF STATEMENTS, FACTS, AND INFORMATION APPEARING ON IDENTIFICATION CARDS AND THESE RESTRICTED OR

CONTROLLED AREA BADGES.

2. APPOINT ACCOUNTABLE OFFICIALS. ACCOUNTABLE OFFICIALS ARE THOSE INDIVIDUALS , MILITARY OR CIVILIAN, WHO ARE DESIGNED IN WRITING AND ARE NOT OTHERWISE ACCOUNTABLE UNDER APPLICABLE LAW, WHO PROVIDE SOURCE INFORMATION, DATA OR SERVICE

TO A CERTIFYING OFFICER IN SUPPORT OF ISSUING PROCESS.

1. ENTER THE NAME OF THE COMMANDER/APPOINTING AUTHORITY

2. ENTER THE COMMANDER/APPOINTING AUTHORITY'S TITLE

3. ENTER THE NAME OF THE COMMANDER/APPOINTING AUTHORITY'S

4. ENTER THE DATE THE FORM IS COMPLETED

5.

8.-10.

THE COMMANDER/APPOINTING MUST PLACE HIS OR HER LEGAL

SECTION II

ENTER THE NAME, COMPLETE ADDRESS, AND PHONE NUMBER OF

6. ENTER THE APPOINTEE'S NAME

7. ENTER THE APPOINTEE'S TITLE

11. ENTER THE DATE THE APPOINTMENT IS TO BE EFFECTIVE

12. CHECK THE APPROPRIATE BOX INDICATING THE PURPOSE FOR THE APPOINTMENT

13. DESCRIBE IN DETAIL THE DUTIES THE APPOINTEE WILL BE REQUIRED TO PERFORM, TO INCLUDE TYPES OF CREDENTIALS, FOR WHICH

AUTHORIZED, AND ANY OTHER PERTINENT INFORMATION

14. LIST ALL REGULATIONS THE APPOINTEE MUST REVIEW AND FOLLOW IN ORDER TO ADEQUATELY FULFILL THE REQUIREMENTS OF THE

APPOINTMENT

SECTION III

15.-16. THE APPOINTEE SHALL PRINT (OR TYPE) HIS OR HER NAME AND ENTER HIS OR HER LEGAL SIGNATURE IN THE SPACES

SECTION IV

17. ENTER THE DATE THE TERMINATION IS EFFECTIVE

18. THE APPOINTEE WILL INITIAL IN THE SPACE PROVIDED ACKNOWLEDGING REVOCATION OF THE APPOINTMENT

20.-22. THE COMMANDER/APPOINTING AUTHORITY MUST PLACE HIS OR HER NAME, TITLE AND LEGAL SIGNATURE IN THE SPACES

PROVIDED

Attachment 9