MEANG Form 4 (Change 20190801).pdf

101st Security Forces Squadron Installation Background Check Request

MEANG Form 4 BACKGROUND REQUEST, 20190801 PREVIOUS EDITION IS OBSOLETE

Please read the Privacy Act Statement on back before completing this form **IMPORTANT** You must provide a valid form of government photo ID that is compliant with the Real ID Act of 2005 in order to access the installation. After October 1, 2020, if you wish to use your Maine driver's license or State ID it must contain a Real ID marker on it (see image below). No exceptions will be made. For more information or to find out about other acceptable forms of ID, log onto https://www.dhs.gov/real-id-frequently-asked-questions

SECTION I

PERSONAL INFORMATION

Last Name: First Name Middle Name: Jr/Sr/II/III

Gender: SSN: Driver’s License #: State of Issue:

Phone # (Include Area Code): Date of Birth (yyyymmdd): Citizenship/Immigration Status

Hair Color: Eye Color: Height: Weight: Demographic:

Have you lived in any other States?

If yes, please list them below along with the physical address:

Home and/or Mailing Address: City: State: Zip Code:

SECTION II

CONTRACTOR INFORMATION

Company, Contractor, or Subcontractor Name:

Supervisor's Name: Supervisor's Phone # (Include Area Code):

Real ID markers (only need one):

https://dbids-global.dmdc.mil/enroll#!/

101st Security Forces Squadron Installation Background Check Request

RELEASE OF BACKGROUND CHECK

In connection with my application to provide services to the Maine Air National Guard (MeANG), I understand that background investigation checks including, but not limited to, criminal convictions, motor vehicle and other reports will be conducted on myself. Furthermore, I understand that the 101st Security Forces Squadron (SFS) will request information from Federal, State, and other agencies that maintain records concerning past activities related to driving, criminal or civil claims.

I authorize without reservation any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for this purpose. This authorization and consent shall be valid in original or electronic form.

Signature: Date:

(Stop here. Return form to Base Point of Contact for processing)

SECTION III

BASE POINT OF CONTACT (POC)

Rank/Name: Office Phone #: On Base Agency Name & Bldg. #:

DBIDS Card/Pass & Length (Select One):

Authorized Access Days & Times

Day of the Week Time In (HHMM): Time Out (HHMM):

Sunday Monday Tuesday

Wednesday Thursday

Friday Saturday

Signature grants approval for individual to obtain a DBIDS card/pass and has a valid purpose for coming onto the installation:

Digital or Wet Signature

Digital or Wet Signature

Privacy Act Statement of 1974 AUTHORITY: 10 U.S.C. 113, Secretary of Defense, Pub. L. 106-65 (Use of Smart Card Technology in the Department of Defense); 10 U.S.C. 136; DoD Directive 1000.25, DoD Personnel Identity Protection (PlP) Program, July 19, 2004; 44 U.S.C. Chap. 35, Government Information Security Act; E.O. 12958, Classified National Security Information as amended by E.O 13142 and 13292; and E.O. 9397 (SSN).

PURPOSE(S): Information on this form will be used by Commanders of DoD installation to determine if an individual meets access control requirements to make positive identification of an individual and to monitor any authorized access to DoD installations and/or facilities.

ROUTINE USE(S): Any release of information contained in this system of records outside of DoD will be compatible with the purposes for which the information is being collected and maintained. The DoD "Blanket Routine Uses" set forth at the beginning of the Office of the Secretary of Defense's (OSD) compilation of systems of records notices apply to this collection.

DISCLOSURE: Voluntary. However, failure to provide the requested information may result in denial of DBIDS card or visitors pass and denial of entry to DoD Installations and/or Facilities.

MEANG Form 4 BACKGROUND REQUEST, 20190801 PREVIOUS EDITION IS OBSOLETE