Attachment 4- DBIDS Card Application.docx
DOCX document 40 KB Posted
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- Laundry and Linen DHA Southern Market
- Solicitation number
- HT940823Q0007
- Issued by
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Defense Health Agency
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DEPARTMENT OF THE AIR FORCE HEADQUARTERS 14TH FLYING TRAINING WING COLUMBUS AIR FORCE BASE MISSISSIPPI
THIS DOCUMENT IS SUBJECT TO THE PRIVACY ACT OF 1974
(SEE BOTTOM SECTION OF DOCUMENT FOR DETAILS)
MEMORANDUM FOR COLUMBUS AFB VISITOR CENTER FROM:
SUBJECT: DBIDS ID Request
Individual Information
| *LAST NAME: |
| *FIRST NAME: |
| MI: |
| *SSN: |
| *DOB: |
| DRIVER LICENSE #: |
| STATE OF ISSUE: |
| COMPANY NAME: |
| BR OF SERVICE: AF |
| EXTENT OF CARD(I.e. 1 year): |
*HRS/DAYS OF BUSINESS AUTHORIZED:
Sponsor/Requester Information
| *LAST NAME : |
| *FIRST NAME: |
| RANK: |
| DUTY TITLE: |
| UNIT: |
| OFFICE SYMBOL: |
| *PHONE NUMBER: |
| HRS/DAYS OF BUSINESS: |
| TYPE OF REQUEST: |
| INITIAL |
RENEWAL
*SIGNATURE:
*MANDATORY INFORMATION – Upon initial issuance of card/pass, for verification, individual must present, to VCC personnel, Driver’s license or photo ID and SS card or document with SSN on it.
**14TH SECURITY FORCES USE ONLY**
Background Check
| COMPLETED BY: |
| COMPLETED ON: |
DATE ISSUED:
| 14 SFS/S5B STAFF SIGNATURE : |
| APPROVED |
DISAPPROVED
PRIVACY ACT STATEMENT
Authority: 10 U.S.C. 8013, Secretary of the Air Force; DoD Directive 7730.47, Defense Incident Based Reporting System (DIBRS); Air Force Instruction 31-203, Security Forces Management Information System; 18 U.S.C. 922 note, Brady Handgun Violence Prevention Act; 28 U.S.C. 534 note, Uniform Federal Crime Reporting Act; 42 U.S.C. 10601 et seq., Victims Rights and Restitution Act of 1990; and
E.O. 9397 (SSN).
Purpose: To apply for a DBIDS Card/Pass (Columbus AFB entry access) Routine Uses: Issuance of DBIDS Card Disclosure: Applicant may be denied access if SSN is not provided.
Columbus Air Force Base
AUTHORIZATION FOR RELEASE OF INFORMATION
Company Name: Phone No:
Address:
FULL NAME (include middle/alias):
SOCIAL SECURITY NO: _ GENDER DOB (mm/dd/yr): DRIVER’S LICENSE NO: STATE: EXP DATE: HOME ADDRESS: CITY STATE: ZIP CODE: HOME PHONE:
SPONSORSHIP AFFILIATION (i.e., son of DoD Contractor John Doe):
I authorize the use of and release of my personal information to Columbus AFB, MS, to accomplish a Wants/Warrants, National Criminal Information Check (NCIC), Security Forces Management Information System (SFMIS) Background Check, to determine access to Columbus AFB in connection with proposed business. Badges are Government Property and I understand I will be held accountable for the badge. Once I am no longer entitled to enter Columbus AFB, I will return my badge. I hereby certify that the above information is true and correct to the best of my knowledge, which certifies the documentation provided to Security Forces is not fraudulent or fictitious.
| SIGNATURE |
| DATE OF REQUEST |
Original documents must be brought with you to the Visitor Venter when receiving your badge.
MUST BRING TWO FORMS OF IDENTIFICATION, ONE WITH PICTURE ID. (See FM I-9)
THE TWO COPIES OF IDENTIFICATION MUST BE GIVEN TO S5B BEFORE BADGE IS ISSUED
Notes: (1) Ensure individuals are briefed to bring their CURRENT documents to include registration, insurance, and driver's license if they are going to be operating a vehicle on the installation. (2) Request forms are valid for 60 days after the request date. After the allotted time, request forms must be reaccomplished.
BADGE EXPIRATION DATE (Not to exceed 1 year):
TO BE COMPLETED BY S5B ONLY
DATE OF BACKGROUND CHECK: VERIFIED BY:
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