J017_SV Forms.pdf

PLEASE PLACE ON COMPANY LETTERHEAD

NAME & ADDRESS OF CONTRACTOR:

Contractor Name Street Address or PO Box City, State, Zip Code

Authorized Point of Contact(s):

POC Name, Company Name, Email Address, Telephone Number

Full Legal Name (Last, First, MI) NCAC Holder

CERTIFICATION

“I hereby certify that all personnel listed above are either born U.S. citizens, naturalized U.S. citizens with the naturalization number shown, or legal aliens with alien registration number indicated and declare under penalty and perjury that all of the information provided on this form is true, complete and correct.”

Contractor POC Printed Name & Title Date

GOVERNMENT SPONSOR ACKNOWLEDGEMENT

Printed Name & Title Date

Date:

SOLICITATION NUMBER & TITLE:

RFP N62742-20-R-1325 J017 UTILITIES & SITE IMPROVEMENTS PHASE II, AREA DISTRIBUTION

NODES AND SITE TELECOM CABLING, US NAVSUPPACT MARINE CORPS BASE, GUAM

NAVAL BASE GUAM

FOREIGN NATIONAL BASE ACCESS REQUEST

Completion of this form will be used solely for law enforcement and force protection purposes and will be handled according to pertaining laws and regulations. Every section of this form must be accurately completed and legible.

The information is necessary for validation of identity and determination of entry eligibility on to Naval Base Guam. Failure to provide this information may result in non-issuance determination by the issuing authority.

Sponsor Information

1. Name (Last, First, MI)

2. Status: Active Duty; Reserve; Retired; Military Dependent; Other:

3. Base Access Identification Card Number (i.e. DODID#):

4. Command/Unit/Company (or closest affiliation):

5. Contact phone number and email address while on Guam: _

6. Address/Residence/Lodging on Guam:

*** A copy of the sponsor valid identification must be provided ***

Sponsor Signature: Date:

Visitor Information

7. Visitor Type: Sponsored Guest; Contractor; Other

8. Full Name(s) of Visitor(s): _

9. Country of Citizenship:

10. Contact Phone Number on Guam: _

11. Residence on Guam (include hotel room number if applicable):

12. Purpose of visit to Naval Base Guam Installation(s): Pre-proposal site visit for project J-017 ADN & STC

13. Intended on Base Destination(s):

14. Beginning and end time(s) requested for access to Naval Base Guam:

*** Copies of Passport, Visa and/or other valid identification are required for all sponsored visitors ***

-------------------------------------------FOR NBG VISITOR CONTROL CENTER----------------------------------

VCC staff that processed Name: _ VCC Staff (Printed Name)

Signature: DATE: _

FN BIOMETRIC DATA

APPLICANT DATA ENTRY (Filled in by applicant not sponsor information)

ROUTING CODE: DATE:

LAST NAME: FIRST NAME:

MIDDLE NAME: SUFFIX:

DATE OF BIRTH: SSN:

SEX: HEIGHT:

RACE: WEIGHT:

EYE COLOR: HAIR COLOR:

PLACE OF BIRTH: CITIZENSHIP:

REASON FOR BIO-DATA:

OCCUPATION:

APPLICANT’S CURRENT RESIDENCE ADDRESS

STREET:

CITY: STATE: ZIP:

EMPLOYER INFORMATION

EMPLOYER/COMPANY NAME:

STREET:

CITY: STATE: ZIP:

-----------------------------------------------FOR NBG VISITOR CONTROL CENTER-----------------------------------------------

Data Entry Completed by:

VCC Staff (Printed Name)

Data Entry Completed by: DATE:

VCC STAFF (Signature)

The information is necessary for validation of identity and determination of entry eligibility on to Naval Base Guam. Failure to provide this information may result in non-issuance determination by the issuing authority.

To attend pre-proposal site visit at NCTS Finegayan, Guam for project J-017

REQUEST FOR CAMERA PASS

U.S. NAVAL BASE GUAM

FOR OFFICIAL USE ONLY

Privacy Act Statement: Pursuant to 5 U.S.C. § 552 and SECNAVINST 5720.42F, this information is being requested on a voluntary basis; however, failure to provide the personal information requested is grounds to deny you entry onto Naval Base Guam property, in accordance with

DODINST 2000.16.

DATE OF REQUEST: Date

COMPANY NAME OR INDIVIDUAL: Company Name

DESCRIPTION OF WORK TO BE PERFORMED:

Contractor pre-proposal, one-day site visit for Request for Proposal N62742-20-R-1325 J017 Utilities & Site Improvements Phase II Area Distribution Nodes and Site Telecom Cabling, US NAVSUPPACT Marine Corps Base, Guam. The resulting contract will construct two (2) Area Distribution Nodes and site improvements including pavement around the buildings for vehicle circulation and parking.

AREA(S) OF ACCESS (Must include Base Name(s), Location(s) and Building #(s) if applicable)

NCTS FINEGAYAN

JUSTIFICATION STATEMENT: Access to this area is required for a pre-proposal site visit to permit potential offerors familiarity with the job site(s). This site visit supports the DPRI program and is for the purpose of preparation of proposals for submission to NAVFAC Pacific.

AUTHORIZED DATE/TIME OF ACCESS:

DATE: 28 May 2020

TIME: 0700 – 1600

DAYS OF ACCESS NEEDED: ONE DAY ONLY

DURATION/EXPIRATION DATE: 28 May 2020

EMPLOYEE(S):

LAST NAME, FIRST NAME: SSN: POSITION/TITLE TYPE OF ID/CARD #

(Note: Full SSN is needed to properly identify persons requesting this pass. Failure to provide this information may prevent Naval Base Guam from processing your request)

NAME XXX-XX-XXXX POSITION/TITLE TYPE OF ID/CARD#

GOVT AGENCY POC: RoAnna K. Peredo, NAVFAC Marianas POC TELEPHONE NUMBER: 671-355-2154 POC EMAIL ADDRESS: roanna.peredo@fe.navy.mil

A STANDARD ADVANCE NOTICE OF ONE WEEK IS REQUIRED, ALTHOUGH BONAFIED EMERGENCIES WILL BE CONSIDERED ON A CASE, BY CASE BASIS. Requests for weekend, non-standard duty hours and access to restricted areas (i.e. the Naval Magazine or Supply) require special consideration and longer processing times. Please take this into consideration when making your requests.

A STANDARD ADVANCE NOTICE OF ONE WEEK IS REQUIRED, ALTHOUGH BONIFIED EMERGENCIES

WILL BE CONSIDERED ON A CASE, BY CASE BASIS. Requests for weekend, non-standard duty hours and access to restricted areas (i.e. the naval magazine or supply) require special consideration and longer processing times. Please take this into consideration when making your requests. Revision (C) - 21 MAR 2019

FOR OFFICIAL USE ONLY

Privacy Act Statement: Pursuant to 5 U.S.C. section 552 and SECNAVINST 5720.42F, this information being requested is on a voluntary basis; however, failure to provide the personal information requested is grounds to deny you entry onto Naval Base Guam property, in accordance with DODINST 2000.16.

REQUEST FOR C BADGE

NOTE: CAC/DBIDS ARE REQUIRED WHEN USING C BADGE. CHECK THE APPROPRIATE BOX

CAC expiration date: DBIDS expiration date:

APPLICANT’S ORGANIZATIONAL INFORMATION

COMMAND NAME:

MAILING ADDRESS:

POINT OF CONTACT:

DESCRIPTION OF WORK

BEING PERFORMED:

ACCESS REQUEST

ONE-DAY REQUEST: NAVAL MAGAZINE:

AUTHORIZATION

DATE OF REQUEST:

AUTHORIZING SPONSOR OR AGENCY POINT OF CONTACT:

POINT OF CONTACT PHONE NUMBER:

POINT OF CONTACT EMAIL ADDRESS:

EXPIRATION DATE (FILLED OUT BY APPROVER):

DATE AUTHORIZED (FILLED OUT BY APPROVER):

TYPE OF ACCESS GRANTED (FILLED OUT BY APPROVER):

SPECIAL ACCESS (FILLED OUT BY APPROVER):

PERSONNEL INFORMATION

NAME COMPANY POSITION

KILO WHARF:

NAVAL BASE GUAM EXPLOSIVE SAFETY NAVAL MUNITIONS SITE HAZARD BRIEF

The purpose of this brief is to ensure that you are aware of the explosive safety requirements and precautions to be taken within the confines of the restricted area and potential explosive site. The possession of a restricted area access badge (C Badge) does not constitute access unless performing official duties or approved contract work.

Naval Munitions site is a restricted area. Due to ammunition and explosive material that are handled on a routine basis in this area, it is also a potential explosive site. Personnel who are visiting any activity on the munitions site are required to check in with the activities point of contact (POC). For maintenance personnel, check in with the respective facilities manager before proceeding to the work site. Maintenance personnel who are assigned to monitor the Fena Lake reservoir are required to access the site via Parson/Harmon Road.

All individuals accessing the restricted area must possess a C Badge. The badge will be retained at the Naval Munitions site security gate until you depart. Ensure you pick up your badge when departing the munitions site.

Only resident employees to Naval Munitions site will retain their badges (white C badges). While in the confines of the restricted area, you are further advised and instructed to consider each unidentified individual as a trespasser and are required to report them to security officials immediately. All C Badges will be approved and signed by the Naval Base Guam (NBG) Security Officer.

The following will also be followed while inside of the restricted area:

1. Unless specifically authorized by the Navy Munitions Command East Asia Division (NMCPAC EAD) Unit Guam Commanding Officer, you will proceed directly to your destination by the shortest approved route and will not enter any area other than you approved destination.

2. Avoid any area where an explosives operation is in progress. These areas are identified with a red flag (Bravo) displayed and placed at the entrance of buildings, magazines, handling, and staging areas.

3. Cellular phones and two way radios will be turned off in the restricted area. If you are required to use a cellular phone or radio, you must have it approved at the NBG Explosive Safety Office, Building 405, located on the Naval Munitions site. All radios and cellular phones will be turned off without exception in Hazards of Electromagnetic Radiation to Ordnance (HERO) areas marked by yellow and red triangular signs.

4. Matches, lighters, or any other flame producing articles are prohibited in the magazine/operating building areas. Smoking is prohibited on the munitions site except in a designated smoking area.

5. The speed limit on the munitions site is 25 MPH unless otherwise posted. There are many sharp curves on roads throughout the site. You are to slow down and stay in your lane going around all curves. Sound your horn at any blind intersection. Explosive laden vehicles always have the right of way.

6. Privately owned vehicles are prohibited on the munitions site. All contractor vehicles must be identified by their respective company logo. The company logo must be affixed on each side of the vehicle. If you are required to leave your government/contractor vehicle unattended while in an area that does not have a designated parking area, ensure the vehicle is parked facing the road and completely off the road’s surface.

PRINT NAME SIGNATURE DATE

NAVAL BASE GUAM EXPLOSIVES SAFETY KILO WHARF HAZARD BRIEF

All individuals accessing restricted areas must possess a restricted area access badge (C Badge). This badge must be presented to security personnel when attempting to gain access to Kilo wharf. Kilo wharf is designated as a restricted area and access must be approved by the Naval Base Guam (NBG) Security Officer. The possession of a C Badge does not constitute access unless performing official duties or approved contract specific work.

The following will also be followed while inside of the restricted area:

1. Only authorized vehicles are allowed on Kilo wharf. All others must park at the Kilo wharf parking lot located at the top of the hill just prior to the first security gate.

2. All personnel must proceed directly to building 5545 to sign-in and state reason for visit.

3. Cellular phones and radios will be turned off while on Kilo wharf. If you require the use of a cellular phone or radio, you must have it approved at NBG Explosive Safety Office, building 405, located on Naval Munitions Site. You must have a Hazards of Electromagnetic Radiation to Ordnance (HERO) sticker affixed to the phone or radio. All radios and cellular phones will be turned off without exception in HERO areas marked by yellow and red triangular signs.

4. Matches, lighters, or any other flame producing articles are prohibited while on Kilo wharf.

Smoking is prohibited except in a designated smoking area. The designated smoking area for Kilo wharf is at the parking lot at the top of the hill.

5. The speed limit on Kilo wharf is 5 MPH. Explosive laden vehicles always have the right of way.

6. Fishing while on the wharf is prohibited. NBG has designated Kilo wharf as a no fishing zone.

NAME SIGNATURE DATE