HMI_Contractors_security__list.pdf

GOLD WATER AIR NATIONAL GUARD BASE

ARIZONA AIR NATIONAL GUARD

SECURITY FORCES

CONTRACTOR ACCESS ENTRY REQUEST

Authority: 10 U.S.C. 8013 and Privacy Act of 1974 Principle Purpose: To establish an entry control access list for personnel needing unescorted access to the installation for the Security Forces Primary Use: For contractors and vendors submitting personnel for background checks for unescorted access to the installation for the purpose of conducting business with the installation.

Disclosure: Information requested is voluntary. Failure to provide any of the requested information will result in access to the installation being denied.

Instructions: This form will be completed by contractors/vendors requesting access for personnel needing privileges to the installation for the purpose of completing a contract for the installation. Once this form is completed and certified by security forces personnel it will be posted at the installation main gate and a copy issued to the installation sponsor and maintained at the security forces administration building. This form should be submitted to CE and Security Forces Pass & ID section NLT 10 duty days prior to the start of the contract to allow for appropriate background and administrative actions to occur. Failure to do so can prevent or delay access. Once completed, this form should be emailed to: 161ARW.CES.CustomerService@us.af.mil & caleb.drane@us.af.mil NOTE: If the form is not completely filled out correctly, it will be returned. If personnel are determined to not have proper clearance to access the installation, this form will be returned to the requester and updated. It will not be considered valid until certified by appropriate SF Personnel.

CONTRACTOR INFORMATION AND REQUEST

Company/Vendor: Company Telephone #:

Contract for/or type of service: Contract Number:

Check on of the following: Prime on the contract: Subcontractor: Vendor:

If Sub-contractor, name of the primary: Job Site Telephone #:

Company Address: Start Date of Contract: End Date:

Job Site:

PERSONNEL ROSTER

First name listed needs to be the local project manager, site supervisor or job foreman for emergency contact or issues concerning employee(s). Please state whether personnel need Un-escorted or Escorted access.

PLEASE TYPE INFORMATION

The following information is supplied and is true and accurate to the best of my knowledge. It is understood that all personnel will receive a background security check.

Signature:

Date:

WHEN FILLED IN, THIS FORM BECOMES FOUO AND CONTAINS SENSITIVE LAW

SECTION 1:

Printed Name of CE Submitter: Signature:

Date: Printed Name of Requesting Contractor:

Handyman Maintenance, Inc. 602-307-0040

Landscaping N/A

P.O. Box 18968 Phoenix, AZ 85005

Base Wide

Handyman Maintenance Inc 12/22/2023

UNESCORTED

Brian Alexander 12/22/2023

SECTION 2

PERSONNEL ROSTER (PLEASE TYPE)

COMPLETE NAME

(LAST, First, Middle)

COMPLETE ADDRESS

(Street, Apt #, City, State, Zip)

FULL

SSN

DOB

(MMDDYYYY)

DRIVER’S LICENSE #

(State and Number)

BACKGROUND CHECKS

COMPLETE OUTCOME

Office Use Only

Date Received: Received From:

Security Forces Representative: Signature:

Gastelum Castellanos, Julio Cesar 5201 W Camelback Rd B49 Phoenix, AZ 85031 600-08-8566 06/10/1975 AZ B12893131 x x x

Albazony, Ali, Mushin 8212 S 74th Ave Laveen, AZ 85339 408-77-1317 11/02/1982 AZ D03230820

Velasquez, Roberto 1829 N 45th Ave Lot 2124 Phoinex, AZ 85035 357-70-7461 11/15/1978 AZ D03796531

Ramos, Auturo, Hernandez 6919 W Mariposa, Phoenix, AZ 85033 502-45-506 02/24/1981 AZ D04398418

ENFORCEMENT AND PRIVACY ACT INFORMATION

Denied

Approved

Approved Approved

CONTINUATION PAGE (PLEASE TYPE)

WHEN FILLED IN, THIS FORM BECOMES FOUO AND CONTAINS SENSITIVE LAW ENFORCEMENT

AND PRIVACY ACT INFORMATION.

1/12/24, 10:53 AM State of Arizona Mail - FW: HMI Contractors https://mail.google.com/mail/u/0/?ik=1b665931f2&view=pt&search=all&permthid=thread-f:1786538735114633233%7Cmsg-f:1786538735114633233&… 1/2

Robert Coleman <robert.coleman@azdema.gov>

FW: HMI Contractors 1 message

ALEXANDER, BRIAN E CIV USAF ANG 161 CES/CEO <brian.alexander.10@us.af.mil> Thu, Dec 28, 2023 at 8:08

AM

To: Robert Coleman <robert.coleman@azdema.gov>

Morning Rob, see below the guys that were approved. I feel like they need more approved; Ali is HMI’s main Foreman and not usually one of the worker bees, so that leaves only 2. Your thoughts?

Thanks, Brian Alexander

Physical Plant Supervisor III

Goldwater ANG Base, Phoenix. AZ

161st ARW/CES/DEMA

602-302-9340

DSN 853-9340

FAX 602-302-9120

From: SWEARENGEN, TRENT L TSgt USAF ANG 161 SFS/ATPM <trent.swearengen.1@us.af.mil> Sent: Thursday, December 28, 2023 7:57 AM To: ALEXANDER, BRIAN E CIV USAF ANG 161 CES/CEO <brian.alexander.10@us.af.mil>; 161 SFS/VCC <161SFS.VCC.VisitorRequests@us.af.mil> Subject: RE: HMI Contractors

Good Morning Mr. Alexander, EAL completed and sent back via DoDSafe. Passphrase: 161ceslandscape

Gastelum, Julio – Approved

Albazony, Ali – Approved

Velasquez, Roberto – Approved

Ramos, Auturo – Denied

If you have any questions, please contact VCC.

mailto:trent.swearengen.1@us.af.mil mailto:brian.alexander.10@us.af.mil mailto:161SFS.VCC.VisitorRequests@us.af.mil

1/12/24, 10:53 AM State of Arizona Mail - FW: HMI Contractors https://mail.google.com/mail/u/0/?ik=1b665931f2&view=pt&search=all&permthid=thread-f:1786538735114633233%7Cmsg-f:1786538735114633233&… 2/2

From: ALEXANDER, BRIAN E CIV USAF ANG 161 CES/CEO <brian.alexander.10@us.af.mil> Sent: Friday, December 22, 2023 11:56 AM To: 161 SFS/VCC <161SFS.VCC.VisitorRequests@us.af.mil> Subject: HMI Contractors

Good afternoon, Can I get these guys ran please? They are for Base landscaping.

v/r

Brian Alexander

Physical Plant Supervisor III

Goldwater ANG Base, Phoenix. AZ

161st ARW/CES/DEMA

602-302-9340

DSN 853-9340

FAX 602-302-9120

mailto:brian.alexander.10@us.af.mil

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