JBC Form 74 Rev 14 May 2015.pdf

Joint Base Charleston (JB CHS) Worksheet for Base Access

Complete Name As it appears on identification

(Last, First Middle) Complete Address

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

SSAN DOB

(MM/DD/YY)

Place of Birth

Driver’s License or ID Card Number and State of issue

NCIC History Log

Date Pass Issued

BADGE

Issued

Section 1:

#1 Company or Vendor Name: #2 Prime/Sub Contractor or Vendor #3 Job Site Phone #: Personal Phone# (Circle One)

#4 Company Phone # (on base #) #5 Days & Times Access is required:

#6 : Description of Work to be performed:

#7 Company Address:

#8 Prime Contractor’s Name (if applicable) #9 Contract for/service provided:

#10 Location of work: JB CHS- AB JB CHS –WS #11 Prime Contract#:

“ See Instruction Item #10 on back of worksheet for Location of Work”

#12 Start Date: #13 End Date: #14 Base Sponsoring Unit: #15 Base Sponsor Info:

(MM/DD/YY) (MM/DD/YY)

(Rank/Name/Phone)

Section 2:

#16 Are you a U.S. citizen? [ ] Yes [ ] No #17 Attach legible copy of state driver’s license or state ID card with clear photo) and a (1) time requirement, a copy of SS card [ ]

#18 Will you require access to the Flight line Restricted Area? [ ] Yes [ ] No Base Sponsor [ ] Yes [ ] No

#19-Industrial Maintenance Complex (IMC) Area?[ ] Yes [ ] No. #20 Have you ever been convicted of a felony? [ ]Yes [ ] No

#21 Do you possess a Military ID? [ ] Yes [ ] No

#22 Please list any visible identifying marks (i.e. birthmarks, tattoos, scars, etc):

The above information is true and correct to the best of my knowledge. The Contractor/Vendor or Designated Supervisor will sign/date below. The Contractor/Vendor Sponsor (Base Contracting Representative or Unit Representative) must also sign and include phone number to verify employment and sponsorship.

Section 3:

#23 Applicant’s Signature/Date: #24 Employment Supervisor/Superintendent:

[ ] I have verified last fiveyears of employment Must be original pen & ink signature, no copies or faxes accepted Signature/Date:

Upon signing, I certify that I have read and understand item #20 on reverse side of worksheet Printed Name:

(attach legible copy of driver’s or state ID card with clear photo and a copy of SS card ) Phone No:

#25 AB Base Sponsor Only [ ] WS Base Sponsor Only [ ] AB/WS Sponsor [ ] #26 Base Sponsor : I understand after completing this worksheet, it “Must be Delivered” to the Visitor

Control Center, building 1953 three days before this Contractor/Vendor arrive to building 1953. _Int.

Signature/Date: Printed Name:

Phone No: CAC DoD Control Number for DBIDS:

Note: The purpose of this worksheet is to control access to the base. It is important that Security Forces knows where everyone is working so pass/badge can be issued correctly.

NOTE: AFTER BASE SPONSOR SIGNS, THE ORIGINAL MUST BE HAND CARRIED TO THE SECURITY FORCES VISITOR CONTROL CENTER (VCC) BUILDING 1953, BY THE BASE SPONSOR OR A CAC CARD HOLDER FROM HIS WORKING GROUP. THE ORIGINAL IS KEPT AT THE 628th SECURITY FORCES CONTRACT SECURITY SECTION (628 SFS/J5Z). INSTRUCTIONS FOR COMPLETING

THIS WORKSHEET ARE ON THE REVERSE SIDE.

JB CHS-AB/WS Contract Security Worksheet for Base Access (14 May 2015) This worksheet is, Official Use Only (FOUO) and must be protected under the Privacy Act of 1974, as amended. Unauthorized disclosure or misuse of this

PERSONAL INFORMATION may result in criminal and/or civil penalties.”

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Section 1: (Fill in all information)

Joint Base Charleston (JB CHS) Worksheet for Base Access Instructions/Guidelines for completing Worksheet

#1 COMPANY/VENDOR NAME: If the company is a (sub) also include the primary company’s name. (i.e. If the Sub is Coke, then the Primary is DECA)

#10 LOCATION OF WORK: [JBC-AB Area 1 Main Base – Area 2 Hunley Park ] [JBC-WS Area 3 Main Base ] [ JBC-AB Area 4 Flight line ( Aircraft Parking Ramp) – Area IMC ( Industrial Maintenance Complex) ] [JBC-WS Area 6 East Side Ord – Area 7 North Side Ord - Area 8 WHARF Alpha – Pier - Area 9 Bravo – Pier – Area 10 Charlie – Area 13 TC Dock – Area 14 Traffic Control [ECP 19-TCI]

NOTE: Badge issued for Contractor to work in Area 4 and the IMC, will have a “RED” back ground.

#14 BASE SPONSOR CONTACT INFO: This is the person that signs the worksheet at the bottom as the base sponsor (#14 & # 25 are the same). Must have a signature letter on file to sign this area.

Section 2: (Fill in all information) NOTE: All the information is important and must be correct.

#17 A copy of a state driver’s license/state issued photo ID; a (1) time requirement, a copy of Social Security Card (SSN); Permanent resident card or Alien Registration Receipt Card (Form 1-551)

#18/19 INDUSTRIAL MAINTENANCE COMPLEX (IMC) and the FLIGHTLINE RESTRICTED AREA 4 are (2) different areas: The IMC area requires you to enter through the access gates are doorways along the flight line. The controlled area consists of the flight line, buildings, and activities that support, maintain and secure the aircraft. Access is controlled through buildings along the perimeter and the vehicle and pedestrian gates. If working in the IMC area mark “YES” for issuance of a badge that allows you access to this area. ACCESS TO FLIGHTLINE RESTRICTED AREA 4

MUST BE CHECKED OFF BY THE BASE SPONSOR.

#20 When answering the FELONY question be honest! If the NCIC investigation produces a positive finding and you answered “NO”, your integrity will be questioned which will/can lead to denial of installation access. Any individual convicted of a felony to include but not limited to: murder, assault with intent to commit murder, rape, extortion, robbery, armed robbery, or any drug offense may be denied access to the installation. In addition, any individual currently on parole, probation or on the Sex Offender Registry will be denied access to the installation. _Int.

Section 3: (Fill in all information) #24 EMPLOYMENT SUPERVISOR: Your job site/contractor supervisor/superintendent for whom you work for.

#26 BASE SPONSOR: A DoD or military approving agency, to include Units that can verify a need for installation access for the purpose of a job/contract (i.e. Contracting Office, DECA, CES, Army Corps of Engineers, etc). Must have signature letter on file to sign this area. Note: (BOTH SIGNATURE ARE REQUIRED FOR JB CHS-AB/WS)

HOW LONG DOES IT TAKE

You do not get the worksheet back once it has been turned into the SFS VCC. The worksheet normally takes 72-hours to process and sometimes longer if discrepancies are found. We appreciate your patience as we work to secure Joint Base Charleston.

CONTRACTOR PASS PROCEDURES

(a) Once the contracting company hires the individual, the individual will be required to fill out all information on the front of this worksheet , so he or she can obtain a pass. It is the responsibility of the company requesting the contractor pass to verify the validity of the employee’s driver license and legal status prior to the request being submitted. Any individual operating a vehicle on the installation must insure that it meets the minimum insurance requirements for the installation and the state of South Carolina. The issuance of a pass is a privilege, which can be withdrawn, and the individual can be barred from base for noncompliance with Joint Base Charleston policies and or USAF directives. This pass must be in the possession of the contractor at all times while on the installation. Contractor pass must be visible on the employee at all times.

(b) When reporting to the Visitor Control Center to obtain an identification badge, each employee will present a valid driver’s license or state issued picture identification.

(c) The pass does not allow family members or friends to be sponsored on the installation at any time. In cases when family or friends must drive the contractor to the base, the drop off point is at the base entry gates. Employees are responsible for their own transportation to the job site.

(d) If the contractor terminates an employee, the contractor will confiscate the employee pass and returned it to Contract Security in Bldg. 1953 (VCC).

(e) Placing Job ads in the newspapers such as “Respond to the base for information, interviews, or employment,” is strictly prohibited. Companies are required to conduct their interviews and employee hiring off base.

(f) Upon completion or termination of the contract or expiration of the identification passes, the prime contractor shall ensure that all base identification passes issued to employees and subcontractor employees are returned to the issuing office, Security Forces in Bldg. 1953, Visitors Control Center (VCC)

(g) Failure to comply with these requirements may result in withholding of final payment.

JB CHS-AB/WS Contract Security Worksheet for Base Access (14 May 2015) Official Use Only (FOUO) which must be protected under the Privacy Act of 1974, as amended. Unauthorized disclosure or misuse of this PERSONAL

INFORMATION may result in criminal and/or civil penalties.”

Controlled Unclassified Information (CUI) denise.sutsko Highlight

Official Use Only (FOUO) which must be protected under the Privacy Act of 1974, as amended. Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in criminal and/or civil penalties.”