Attachment_JL-4_NSAA_Base_Access_Forms.pdf

Solicitation No.

N40192-19-R-9200

GROUNDS MAINTENANCE

AND TREE TRIMMING SERVICES

VARIOUS MILITARY INSTALLATIONS,

Guam Marianas Islands and Northern Marianas Islands

ATTACHMENT JL-4

NAVAL SUPPORT ACTIVITY ANDERSEN GUAM

BASE ACCESS REQUEST FORMS

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

LAST, FIRST MI

Revised on September 21, 2012 USAF Base 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 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 personnel 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: _______________________________

Office Name: ___________________________________________ Office Number: ______________________________

Processing Officer: __________________________________________

Company Logo

TRACKING#

DATE:

Memorandum for 36 SFS/S5/VISITOR CONTROL CENTER

From: Company/Base Agency

Subject: Request for Contractor Pass/ GROUNDS MAINT. SITE VISIT N40192-19-R-9200.

1. The request is for Andersen Air Force Base access.

REQUESTED DATES

START: 24 JULY 2019

END: (max 1 year) 24 JULY 2019

DAYS (check all that apply)

□ Su □ Mo □ Tu □ We □ Th □ Fr □ Sa □ 24/7

TIMES ACCESS DAYS/TIMES

START: 0700

END: 1600

2. The request includes the following individuals. (See Attached Log Information). Individuals listed on the log will be issued a pass with the appropriate dates/times listed above.

3. If you have any questions or concerns, contact 123@email.com or 671-123-4567

///COMPANY REPRESENATIVE SIGNATURE///

CEO BULLDOSER INC.

Phone Number

///AUTHORIZED SIGNATURE///

CONTRACTING OFFICER

mailto:123@email.com