N4019218R1300_AAFB_Base_Pass_Forms.pdf

RN

REQUEST

TYPE

QH/QR

III REQUESTER

DATE OF

REQUEST

SUBJECT FBI DOB SSN

PUR

CODE C/

J/ F/ H/ D

SPECIFIC REASON FOR III

REQUEST LIST

ASSOCIATED

INVESTIGATION AND

INDICATE IF QUERY MADE

AT TIME OF ARREST

1 QH C MG-Base Access

2 QH C MG-Base Access

3 QH C MG-Base Access

4 QH C MG-Base Access

5 QH C MG-Base Access

6 QH C MG-Base Access

7 QH C MG-Base Access

8 QH C MG-Base Access

9 QH C MG-Base Access

10 QH C MG-Base Access

11 QH C MG-Base Access

12 QH C MG-Base Access

13 QH C MG-Base Access

14 QH C MG-Base Access

15 QH C MG-Base Access

16 QH C MG-Base Access

17 QH C MG-Base Access

18 QH C MG-Base Access

19 QH C MG-Base Access

20 QH C MG-Base Access

21 QH C MG-Base Access

22 QH C MG-Base Access

23 QH C MG-Base Access

24 QH C MG-Base Access

25 QH C MG-Base Access

26 QH C MG-Base Access

27 QH C MG-Base Access

28 QH C MG-Base Access

29 QH C MG-Base Access

30 QH C MG-Base Access

Revised on September 21, 2012 USAF Contractor/Sub-Contractor Access Affidavit This data will be used to screen individuals who have or are seeking access to US Air Force installations or facilities controlled by the US Air Force. Please answer each question. Access will be denied if this questionnaire is incomplete or missing from the Contractor Access packet. This information will be used to generate state and federal criminal history records checks.

A. PERSONAL INFORMATION

1. NAME (PRINT LAST, FIRST, MIDDLE): __________________________________________________________2. EMAIL:________________________________

3. MAIDEN NAME OR ALIAS: _____________________________________________________________________________________________________

4. SEX: _____ 5. SSAN: _________________________________ 6. DATE OF BIRTH: _______________ 7. RACE: _____________________

8. HAIR COLOR: _______________ 9. EYE COLOR: _____________ 10. HEIGHT: ____________ 11. WEIGHT: _____________

12. DRIVERS LICENSE #: _______________________________ 13. STATE: ____________ 14. HOME AND CELL PHONE #: ____________________________

15. CURRENT AND ON-ISLAND RESIDENCE ADDRESS: _____________________________________________________________________

16. CITY: _________________________ 17. STATE: ________________ 18. ZIP CODE: ________________19. HOW MANY YEARS ON ISLAND? _____________

B. PLACE OF BIRTH

CITY: _____________________________ STATE: _________________ COUNTRY: ______________________ CITIZENSHIP: ________________________

C. CRIMINAL HISTORY (Circle YES/NO)

1. Have you ever been barred from entry/access to any military installation or facility? YES NO Date______________________ Installation________________________

2. Are you wanted by federal or civilian law enforcement authorities, regardless of offense or violation? YES NO (i.e., has a judge issued an order for your arrest?)

3. Have you ever been convicted of a firearms or explosives violation? YES NO

4. Have you ever been incarcerated for 12 months or longer? YES NO

5. Have you ever been convicted of espionage, sabotage, treason or terrorism, murder, assault, sexual assault, YES NO Armed assault or robbery, rape, child molestation, drug possession, or drug distribution?

D. IMMIGRATION/WORKING STATUS (attach copies of all documentation)

Circle appropriate answer, and provide proper numbers.

6. Do you have a VISA? YES NO VISA #________________________________________

A. What type of VISA? Immigration VISA Non-Immigration VISA

B. What VISA Classification? H2 W1 B1 Other_____

7. Do you have a Form I-551 (Resident Alien/Green Card)? YES NO I-551 #________________________________________

8. Do you have an I-94? YES NO I-94 # _________________________________________

9. Do you have an Employment Authorization Document YES NO EAD/WAC #___________________________________ or WAC?

10. Do you have other Immigration Documents? YES NO Document & # __________________________________ (If YES, list type of document and number)

NOTE TO APPLICANT: ATTESTATION

I attest to the fact that I have been briefed by my employer and understand the purpose for the contractor background check. I understand the information on this form is being collected in accordance with 50 U.S.C., Section 797, and DoDD 5200.8 federal laws permitting the installation commander to limit access to the installation for security reasons and that this data will be used to screen DoD contractor employees who have or are seeking access to US Air Force installations. I have voluntarily completed this “Form” and shall provide the Air Force a specimen of my fingerprints, if/when requested. I understand that by signing this application, I acknowledge that I have been made aware of and have reviewed that Air Force’s list of “disqualifying factors” above. I hereby give my consent and authorization for the Air Force to conduct any additional background screenings deemed necessary over the next 12 months, to include comparing/checking my fingerprints against local, state, and federal criminal databases. The information I have provided on this application is true, complete, and correct to the best of my knowledge and belief, and is provided in good faith. I understand that a knowing and willful false statement on this application can be punished by a fine or imprisonment or both. (18 U.S.C. Section 1001)

Applicant Signature: ________________________________________ Date: _______________________________

Company Name: ___________________________________________ Contract Number: ______________________________

Processing Officer: __________________________________________

1249738707C Typewritten Text

1249738707C Typewritten Text

DEPARTMENT OF THE AIR FORCE

HEADQUARTERS 36TH WING (PACAF)

ANDERSEN AIR FORCE BASE GUAM

Foreign National Access Request Form Contractor Request

APPROVED BY: ___________________________ TRACKING NUMBER: _______________________ FVR NUMBER: _________________

PROJECT COORDINATOR CONTRACTING OFFICER

First Name

Last Name:

Contact Phone Number:

Email Address:

Organization:

Visitor 1 Visitor 2 Visitor 3 Visitor 4 First Name:

Last Name:

Date of Birth:

DD / MMM / YYYY

Country of Citizenship:

Identification Type

[] Passport [] I-94 [] U.S. Visa [] Other:___________

[] Passport [] I-94 [] U.S. Visa [] Other:___________

[] Passport [] I-94 [] U.S. Visa [] Other:___________

[] Passport [] I-94 [] U.S. Visa [] Other:___________

Occupation:

Relationship to Escort:

How long is your stay on Andersen AFB?

From:________/________/________

DD MMM YYYY

To:________/_________/_________

Purpose of visit to Andersen?

Address while on Guam:

Street

_________________________,, Guam _______ City Zip

PRIVACY ACT STATEMENT: AUTHORITY: Title 5 USC Section 301, Departmental Regulation Principle Purpose: To record personal information and determine access to the installation ROUTINE PURPOSE: To request and record the issuance of a Visitor Pass when the use of another form is not authorized or specified. Failure to provide any information requested may result in non-issuance of the Visitor Pass. Disclosure of information is voluntary acceptance of these terms constitutes approval for a background check to be conducted as part of the request approval process. The information is necessary for validation of identity and determination of entry eligibility on to Andersen Air Force Base. Failure to provide this information may result in non-issuance determination by the issuing authority.