N4019220Q3004_0001_Encl.02_BaseAccessForms.pdf

Contract No.

N40192-20-Q-3004 Amendment 0001

Enclosure (2)

PHYSICAL SECURITY MAINTENANCE SERVICES

FOR NAVAL COMPUTER &

TELECOMMUNICATION STATION (NCTS),

MARINE CORPS BASE, CAMP BLAZ (MCB CB)

BASE ACCESS REQUEST FORMS

Date:

To: Ms. Elizabeth E. Balajadia, Naval Base Guam (NBG) Visitor Control Center Supervisor From:

Subj: BASE ACCESS REQUEST -

CONTRACT INFORMATION:

Contract No./ Title:

Contract Start & Expiration Date:

Prime Contractor Name:

Prime Contractor Address:

Contractor Coordinator:

(Name, Title & Phone Number)

Project Location(s) on Naval Base Guam Installation:

(Check mark all that apply)

Main Base Apra View Housing Apra Palms Housing NAVMAG Polaris Point Turner Housing Flag Circle JRM Naval Hospital

NCTS

Required Access Dates:

(Applies only when dates differ from the contract dates stated above.) From: To:

Required Access Days & Times:

EMPLOYEE INFORMATION:

On company letterhead, attach list all employee(s), requiring base access under this contract. List your sub-contractor employees separately. See attached page for format guidance.

SPONSOR INFORMATION:

Name & Title:

Command:

Phone No:

Email Address:

The above listed Prime Contractor is authorized to operate on-board Naval Base Guam Installation. The above listed Prime Contractor Coordinator will provide and liaison directly with NBG Visitor Control Center, all required contractor employee information, to include sub-contractor employee information, for the purpose of securing authorized base access credentials.

Government Sponsor Signature:

Other (Specify):___________________________

(e.g. MON-FRI/0600-1800)

Angela.Santos Highlight

Angela.Santos Typewritten Text NOTE: Contractors must include document to establish identity. Acceptable identification include U.S. Passport or U.S. Passport Card, Permanent Resident Card, Real I.D., and other documents indentified on page 3 of the SECNAV 5512/1 form.

DATE:

CONTRACT NUMBER & TITLE:

Name & Address of Sub-Contractor: (If applicable)

Full Legal Name (Last, First, MI) NCAC Holder

CERTIFICATION:

"I hereby certify that all personnel listed above are either born U.S. citizens, naturalized U.S. citizens with the naturalization number shown, or legal aliens with the alien registration number indicated and declare under penalty and perjury that all of the information provided on this form is true, complete and correct”.

Contractor POC Printed Name & Title Date

GOVERNMENT SPONSOR ACKNOWLEDGEMENT

Printed Name & Title Date

Typewritten Text

Typewritten Text

Angela.Santos Text Box DBIDS Number

0MB 0703-0061 Exp. 31 Mar 2017

DEPARTMENT OF THE NAVY LOCAL POPULATION ID CARD/BASE ACCESS PASS REGISTRATION

PRIVACY ACT STATEMENT:

AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters. Marine Corps; OPNAVINST 5530.14E, Navy Physical Security; Marine Corps Order 5530.14A, Marine Corps Physical Security Program Manual; and E.O. 9397 (SSN), as amended, SORN NM05512-2.

PURPOSE(S): To control physical access to Department of Defense (DoD), Department of the Navy (DON) or U.S. Marine COIJ)s Installations/Units controlled information, installations.

facilities, or areas over which DoD, DON, or U.S. Marine Corps has security responsibilities by identifying or verifying an individual through the use of biometric databases and associated data processing/information services for designated populations for purposes of protecting U.S./Coalition/allied government/national security areas of responsibility and information; to issue badges, replace lost badges. and retrieve passes upon separation: to maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/exit times of personnel.

ROUTINE USE(S): To designated contractors, Federal agencies, and foreign governments for the purpose of granting Navy officials access to their facility.

DISCLOSURE: Providing registration information is voluntary. Failure to provide requested information may result in denial of access to benefits, privileges, and DoD installations, facilities and buildings.

IDENTITY PROOFING AND APPLICANT INFORMATION

1. LAST NAME:

5. HISPANIC OR

LA TINO (Check one):

7. GENDER

(Check one):

2. FIRST NAME:

DYES D NO 16· RACE D WHITE

(Check one or more):

0MALE 0FEMALE

8. DATE OF BIRTH:

3. MIDDLE NAME:

DAFRICAN AMERICAN

OR BLACK

9. CITY OF BIRTH:

4. NAME SUFFIX:

0Jr. D Sr. 01 011 0111 DIV

D ASIAN D AMERICAN INDIAN OR

Al.ASKIN NATIVE

NATIVE HAWAIIAN

DOR OTHER PACIFIC

ISLANDER

'IQ STATE OF BIRTH: 11. BIRTH COUNTRY:

12. US CITIZEN (Check): DYES ONO 113. DUAL CITIZENSHIP: DYES ONo CITIZENSHIP IF OTHER THAN US (Country)

U.S. Citizen Minimum Documentation Required:

By Birth - Social Security No and/or State ID/Drivers License.

Naturalized - Certification Number, Petition Number, Date, Place and Court, United States passport number, Social Security No and/or

State ID/Drivers License.

Derived - Parent's certification number, Social Security No and/or State ID/Drivers License.

Alien Minimum Documentation Required:

Registration Number, Expiration date, Date of entry, Port of entry.

14. IDENTITY SOURCE 15. DOCUMENT NUMBER: 16. ISSUED BY 17. ISSUED BY 18. ISSUED: 19. EXPIRES: DOCUMENTS PRESENTED: STATE/COURT: COUNTRY:

D Social Security No. United States

0 State ID/Drivers License United States

0 Passport No.

D Certification Number and Petition Number

D Derived - Parent's Certification Number: United States

D Alien Registration No. United States

Date of Entry: I Port of Entry:

OTHER APPROVED IDENTITY SOURCE DOCUMENTS:

D D

20. WEIGHT 21. HEIGHT 22. HAIR COLOR (Check one): 23. EYE COLOR (Check one):

(Pounds): (Inches): D Blond D Brown D Black D Gray D Red D Brown D Green D Blue D Hazel

D White D Silver D Auburn D Bald D Black D Gray n Violet D Unknown

24. HOME ADDRESS (Include city, state, zip code): HOME PHONE (Include Area Code):

L::>. t:lA::,t: ::,1-'uN::,ut<;:, NAMt:: SPONSOR PHONE (Include Area Code):

EMPLOYMENT ACTIVITY INFORMA TON

LO. t:Ml-'LUJ't:H NAMc ANU "·-'!... ___ (Include city/state/Zip code): t:Ml-'LU y t:H 1-'HUNt: (Include Area Code):

LI. ::,ui--"'" \/ 1:::iuK NAMt. ANU AUUKt.SS (Include city/stale/Zip code): SUPERVISOR PHONE (Include Area Code):

SECNAV 5512/1 (APR 2014) FOR OFFICIAL USE ONLY WHEN FILLED - PRIVACY SENSITIVE: Page 1 of 3 Any misuse or unauthorized disclosure of this information may result in both criminal and civil penalties.

Angela.Santos Typewritten Text Angela Santos, Contracting Officer, NAVFACMAR/MCB CB PWD

Angela.Santos Typewritten Text 671-355-8817

Angela.Santos Sticky Note Wet signature only

Angela.Santos Sticky Note Initial 29 and 30

Pages from Attachment JL-4_Base Access Forms.pdf