Site Visit New Pass Registration.xlsx
XLSX spreadsheet 24 KB Posted
- Attached to
- P-5001 DBB, JOINT AIR DEFENSE OPERATIONS PHASE II, JOINT BASE ANACOSTIA-BOLLING, WASHINGTON, DC
- Solicitation number
- N4008021R3502
About this file
This document contains a federal contract opportunity solicitation and a related site visit registration form. The solicitation is for the completion of the second phase of construction of a two-story Joint Air Defense Operations Center at Joint Base Anacostia-Bolling in Washington, D.C. The construction work includes a concrete foundation, structural steel frame, concrete masonry walls, roofing system, pavements, utilities, site improvements, security fencing, and communication routing. The facility must meet Department of Defense, Air Force, and Joint Base design standards and use local materials where cost-effective. It will be designed to antiterrorism and force protection requirements. The related registration form collects applicant information such as name, date of birth, citizenship status, identification documents, employer details, and authorization for background checks in order to register for a site visit regarding the solicitation opportunity.
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Text version
Sheet1
| JOINT BASE ANACOSTIA-BOLLING LOCAL POPULATION ID/BASE ACCESS PASS REGISTRATION FORM | ||||||
| PLEASE COMPLETE BOTH SIDES OF FORM | ||||||
| PRIVACY ACT STATEMENT: This information is protected under the Privacy Act of 1974. This form will be considered confidential when filled out. | ||||||
| AUTHORITY: 10 U.S.C., Department of Defense Manual (DoDM) 5200.08 Volume 3, AFMAN 31-101_Volume 3 I.A.C. & AFI 31-101 Integrated Defense | ||||||
| PURPOSE(S): To control physical access to Department of Defense facilities over which the 11th Security Forces Squadron has law enforcement jurisdiction. | ||||||
| ROUTINE USE(S): To designated contractors, Federal agencies, and foreign officials for the purpose of granting access to this DOD/USAF installation. | ||||||
| DISCLOSURE: Providing registration information is voluntary. Failure to provide requested information may result in denial of access to this installation. | ||||||
| APPLICANT INFORMATION | ||||||
| 1. LAST NAME: | 2. FIRST NAME: | 3. MIDDLE NAME: | 4. SUFFIX: | |||
| 5. GENDER (CIRCLE ONE) MALE OR FEMALE | 6. SOCIAL SECURITY NUMBER | 7. DATE OF BIRTH: | 8. CITY/STATE OF BIRTH: | 9. COUNTRY OF BIRTH: | ||
| 10. U.S. CITIZEN (CIRCLE ONE): YES NO | 11. CITIZENSHIP, IF NOT U.S. (COUNTRY): |
12. WEIGHT (POUNDS): 13. HEIGHT (INCHES): 14. HAIR COLOR: 15. EYE COLOR:
| 16. HOME ADDRESS (INCLUDE CITY, STATE, ZIP CODE): | 17. CELL/HOME PHONE: | |||||
| IDENTIFICATION DOCUMENTS | ||||||
| 18. STATE ID/DRIVER'S LICENSE: | 19. STATE ISSUED | 20. DATE ISSUED | 21. DATE EXPIRES | |||
| 22.PASSPORT NUMBER | 23. COUNTRY ISSUED | 24. DATE ISSUED | 25. DATE EXPIRES | |||
| 26. GREEN CARD NUMBER | ||||||
| 27. DATE ISSUED | 28. DATE EXPIRES | |||||
| 29. OTHER APPROVED IDENTIFICATION | 30. DATE ISSUED | 31. DATE EXPIRES | ||||
| FOR CONTRACTORS/SERVICE/VENDER PROVIDERS: EMPLOYMENT ACTIVITY INFORMATION | ||||||
| 32. COMPANY NAME AND ADDRESS (INCLUDE CITY/STATE/ZIP CODE): | 33. COMPANY PHONE NUMBER | |||||
| 34. SUPERVISOR NAME AND ADDRESS (INCLUDE CITY/STATE/ZIP CODE): | 35. SUPERVISOR PHONE #: | |||||
| PRIOR FELONY CONVICTIONS | ||||||
| 36. HAVE YOU EVER BEEN CONVICTED OF A FELONY? | YES | NO | INITIAL: ____________ | |||
| REQUIREMENT TO RETURN LOCAL POPULATION ID CARD | ||||||
| 37. I UNDERSTAND THAT I AM REQUIRED TO RETURN MY LOCAL POPULATION IDENTIFICATION CARD TO THE JOINT VISITOR CONTROL CENTERWHEN IT EXPIRES OR IF MY EMPLOYMENT IS TERMINATED FOR ANY REASON. | INITIAL: ____________ |
| AUTHORIZATION/RELEASE: | |
| 38. I hereby authorize the USAF/DOD and other authorized Federal agencies to obtain any information required from the Federal government and/or state agencies, including but not limited to , the Federal Bureau of Investigation (FBI), the Defense Security Service (DSS), & the U.S. Department of Homeland Security (DHS). I have been notified of USAF right to perform minimal vetting and fitness determination as a condition of access to DOD/USAF installations. I understand that I may request a record identifier; the source of the record and that I may obtain records from the state Law Enforcement Office as may be available to me under the law. I also understand that this information will be confidential. | |
| RELEASE (CONT.) AND CERTIFICATION | |
| 39. I release any individual, including records custodians, any component of the U.S. Government or the individual State Criminal History Repository supplying information, from all liability for damages that may result on account of compliance, or any attempts to to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representatives of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me. |
FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD RESULT IN FINES AND/OR IMPRISONMENT UP TO 5 YRS.
BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE YOU COMPLETED ALL QUESTIONS CORRECTLY.
| I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE BY ME ON THIS FORM ARE | ||
| TRUE, COMPLETE AND CORRECT. | ||
| 40.GOVERNMENT SPONSOR NAME AND AGENCY: | ||
| 41. SPONSOR/ DoDI NUMBER | 42. GOVERNMENT SPONSOR PHONE NUMBER |
| CRIMINAL HISTORY BACKGROUND CHECK IS REQUIRED FOR BASE ACCESS |
| I have been advised of the required crimal history background check and given my consent by providing my sigature in this block. |
DATE: ________________ SIGNATURE: ________________________________
| COMPLETED BY JOINT VISITOR CENTER PERSONNEL | ||||
| 43. INFORMATION VERIFIED BY: | 44. REGISTRATION EXPIRATION DATE | 45. VEHICLE INSURANCE EXPIRATION DATE | ||
| 46. BACKGROUND (OpenFox) PERFORMED BY: | 47. RESULTS OF BACKGROUND CHECK: | |||
| 48.VETTED DATE | 49.VETTED EXPIRATION DATE | |||
| 50. DURATION | PAPER | CARD | 51. COMPANY NAME- SUB OF AGENCY- | |
| 52. DBIDS OPERATOR | TIMES AND DATES OF VISIT | |||
| EXPIRATION DATES | ||||
| FOR OFFICIAL USE ONLY |
JBAB 5512 BASE ACCESS REGISTRATION FORM APR-2021 &P
File details come from the government source that posted it. Updated .