MCLBB Vetting Form.pdf

FOR OFFICIAL USE ONLY

Marine Corps Logistics Base, Barstow (MCLBB) CA Vetting and Clearance Form

(U) The Vetting Program instills confidence in the civilian or contractor employed by MCLBB. Further, the program provides a basis to ensure

Anti-terrorism requirements are being fulfilled as prescribed in the MCLBB All Hazards Incident plan. Vetting of personnel will be conducted annually or upon request. Vetting is performed through interview by the potential employer. Based on these reviews, assurances can be established that the Vetting Policy is being implemented as intended. The vetting process is specific in scope covering areas such as credential checks. The results of the credential check will determine the ability of employment. The requested information falls under the Freedom of Information Act (FOIA) for the purpose of a background investigation for entry onto MCLBB. Information provided will be maintained within the Security & Emergency Services and MCLBB. The entire process will take 10 days to clear from the time the form is submitted by the Contractor with signatures. Each section of this form must be completed in its entirety.

SECTION 1: ACTIVITY REQUESTING INFO – To be completed by Government Sponsor Upon completion of this form, e-mail it for processing at: BSTWPBA.FCT@USMC.MIL

MCLBB Activity/Office: Location/Building #:

Point of Contact: Phone#:

Alternate: Phone #:

Contractor’s Company Name: Sub-Contractor’s Company Name:

Contract #: Contract Title:

Contract Initiation Date: / / Completion Date: / / Month Day Year Month Day Year

SECTION 2: PERSONAL DATA – To be completed by Applicant

Last Name: First Name: MI:

Complete Address:

Home Phone: Cell: SSN# _XXX-XX-

Drivers License #: State: Valid State ID #: State:

Date of Birth: / / Place of Birth:

Month Day Year

Height: Weight: Color of Eyes: Color of Hair: Sex: Race:

Scars or Tattoos:

SECTION 3: VEHICLE INFORMATION – Personal and/or Commercial

Make: Model: Year: License Plate #: Vin # (Last 8):

Collection of the information requested by this form is authorized under: National Security Act of 1947; as amended; Public Law 104-134 (April 26, 1996). The information will be used to help make personnel security determinations, including whether to grant or allow access to MCLBB.

The data may later be used as part of a review process to evaluate continued eligibility for access.

This form supersedes all other forms. All other forms are obsolete and will not be processed. (Rev 06/12) initiator:BSTWPBA.FCT@USMC.MIL;wfState:distributed;wfType:email;workflowId:e6a15070a096b6479d777ade3e5fc26c

SECTION 4: GENERAL INFORMATION

Do you possess a Military ID: Yes No Expiration Date:

Active Duty Reserves Dependent Retired

Do you possess a CAC card: Yes No Expiration Date:

SECTION 5: APPLICANT UNDERSTANDS: (Initial each block)

I understand I am applying for the position of and my employer is

I understand issued ID badges will be worn and visible at all times.

I will adhere to all California Laws and Base Regulations or directions.

I will not carry, possess, or hold any weapon (s) while on MCLBB.

I will not be in any possession of a camera or any photographic capable device without prior authorization while on MCLBB.

I understand the receipt of a base pass only grants me permission to enter the base to perform the duties in which I am being hired for. (Contractor’s Only)

I understand the only place in which I am authorized to go on base is to my place of employment.

(Contractor’s Only)

I understand I am not an employee of any Federal agency or activity and my sole sources of compensation is from my employer. (Contractor’s Only)

Violations of any of the above items or any law or regulations could result in my barment from base and/or legal arrest.

I hereby certify that I will abide by all federal, state, local, and base law or regulation. I further understand I may gain access to MCLBB for employment or for official business only. I also understand myself and my vehicle are subject to search by competent authority while aboard MCLBB.

I hereby certify that the above information is true and complete to the best of my knowledge. I understand refusal to answer any question or the submission of incorrect or misleading information may be the basis of denying, suspending, or revoking my privileges.

Have you EVER been convicted of any offense to include traffic violations? Yes No If yes, provide detailed information (Date, violation, disposition…..)

Applicant’s Signature Date

Government Sponsor’s Signature Date

This form supersedes all other forms. All other forms are obsolete and will not be processed. (Rev 06/12)

INSTRUCTIONS FOR PROCESSING OF

Marine Corps Logistics Base, Barstow (MCLBB) CA

Vetting and Clearance Form

1. Government Sponsor, Contractor and Applicant must complete and sign the entire form.

2. Designated Government Sponsor will email Page 1 to:

BSTWPBA.FCT@usmc.mil. Email must come from a .mil address;

(ctr.mil addresses will not be accepted.)

3. On the first day of employment, Applicant will hand deliver the original Vetting and Clearance form pages 1 and 2 to the Pass and ID section, bldg 101.

4. If additional information is required, when the Government Sponsor contacts Pass and ID they will be notified and they must notify the Applicant to contact Pass & ID within five (5) working days.

5. Each section of this form must be completed in its entirety!

Failure to follow the above instructions WILL delay the process.

6. If you have any questions please contact Pass and ID.

This form supersedes all other forms. All other forms are obsolete and will not be processed. (Rev 06/12)

9.0.0.2.20101008.1.734229 initiator:BSTWPBA.FCT@USMC.MIL;wfState:distributed;wfType:email;workflowId:93863472a0452647b7ec10669053caa5