EscortOnlyCIW.doc.pdf

For Official Use Only

“Escort Only” Contractor Information Worksheet (CIW) Version 1 (Updated 06/20/16)

(Modified for Use by Region 5) Sponsoring Office Symbol

GSA Region (Options on Pg.2) 5-Escort

1. Contract Employee Information (filled out by contractor only) Name (Last/Family)

First (Given)

Middle (or NMN if none)

Suffix

Social Security #

Date of Birth

Place of Birth (POB): City

POB: State

Country

Sex Male or Female:

Home Address Street e-Mail

Address Street (line 2)

Phone Number (Day)

Phone Number (Cell)

City

State

Zip

Position (Job) Title

U.S. Citizen

Non-U.S. Citizens Only: Port of Entry City and State

Date of Entry

Alien Registration #

Citizenship Country

2. Contact Information (filled out by GSA or Company POC) Company Name

Company is Sub or Prime:

If Sub, Name of Prime

Task Order (TO) / Delivery Order (DO) Number/ (Enter Contract Base Number if TO / DO is Not Applicable) Micro purchase/credit card

Contract Number Type List Task/Delivery or Base:

Contract Start Date

Contract End Date

Has option Yrs. List how many

Company Point of Contact (POC) Name

POC Phone Number (Day)

POC Email Address

3. Project/Work Location Information (Government site where contractor is working) (filled out by GSA or Company POC) GSA Building Number

OH0033ZZ

Building Name Howard M. Metzenbaum U.S. Courthouse

Building Address 201 Superior Ave., Cleveland, OH 44114

4. Name of Escort and Start/Stop Dates: (filled out by GSA and Escort if contractor) Escort’s Full Legal Name: (Last, First Middle Suffix)

Escort’s SSN (if a contractor) if they don’t have a GSA PIV card:

Escort Start Date:

Escort Stop Date:

5. Requesting Official (Sponsor) Information (filled out by GSA) Sponsor’s Name

Title

Email Address Phone Number (Day)

Date Forms Were Reviewed

Alternate POC or Comments

List Supervisory Property Managers name in Alternate POC