I_-_JB_CHS-_Contract_Security_Form_74_-_Revised.pdf

Complete Name As it appears on identification

(Last, First Middle) Complete Address

(Street, Apt Number, City, State, Zip)

SSAN DOB

(MM/DD/YY)

Place of Birth

Driver’s License or ID Card Number and State of issue

NCIC History Log

Date Pass Issued

BADGE

Issued

Section 1:

#1 Company or Vendor Name:___________________________#2 Prime/Sub Contractor or Vendor #3 Job Site Phone #:_________________Personal Phone# (Circle One)

#4 Company Phone #__________________________ (on base #)_________________________________ #5 Days & Times Access is required: WEDNESDAY, FEBRUARY 05, 2014, 0730 – 1600

#6 : Description of Work to be performed ATTENDANCE AT PRE-PROPOSAL CONFERENCE & SITE VISIT FOR NPTU PROJECT NO. P-99 & P-100

#7 Company Address: ________________________________________________________________________________________________________________________________________________________________

#8 Prime Contractor’s Name (if applicable)___________________________________ #9 Contract for/service provided: OFFERORS SITE VISIT FOR PLANNED CONSTRUCTION OF P-99 &P-100

#10 Location of work: JB CHS- AB JB CHS-WS AREA 3 – NPTU #11 Prime Contract#:____SOLICITATION NUMBER: N69450-14-R-1756 _ _ “ See Instruction Item #10 on back of form for Location of Work”

#12 Start Date: 02/05/14 #13 End Date: 02/05/14 #14 Base Sponsoring Unit: ROICC #15 Base Sponsor Info: MICHAEL W. MORGAN (843) 794-4324

(MM/DD/YY) (MM/DD/YY) (Rank/Name/Phone)

Section 2:

#16 Are you a U.S. citizen? Yes No #17 If no, please provide INS Form I-9 or subsequent information

#18 Are you a Job Site Verifying Official for this project? Yes No Sponsor’s initials (if yes)_____ 19 Will you require access to the Flight line Restricted Area? Yes No

#19-a Industrial Maintenance Complex (IMC) Area ? Yes No. #20 Have you ever been convicted of a felony? Yes No

#21 Do you possess a Military ID? Yes No

The above information is true and correct to the best of my knowledge. The Contractor/Vendor or Designated Supervisor will sign/date below. The Contractor/Vendor Sponsor (Base Contracting Representative or Unit Representative) must also sign and include phone number to verify employment and sponsorship.

Section 3:

#22 Applicant’s Signature/Date:______________________________ #23 Employment Supervisor/Superintendent:

Must be original pen & ink signature, no copies or faxes accepted Signature/Date: ______________________ Upon signing, I certify that I have read and understand item #20 on reverse side of form Printed Name:________________________ (attach legible copy of driver’s license or state ID card with clear photo) Phone No:______________________________

(BOTH SIGNATURE ARE REQUIRED FOR JBC- AB/WS ) __ I have verified last five years of employment

#24 AB Base Sponsor (see reverse): #25 WS Base Sponsor (see reverse): #26 SFS/S5X Official:

Signature/Date:_____________________ Signature/Date:___________________ Signature/Date: _________________ Printed Name: __________________ Printed Name: MICHAEL W. MORGAN Printed Name:_______________ Phone No:_________________________ Phone No: (843) 794-4324 SSN (Last Four) :___________________ SSN (Last Four): SEE LIST Note: The purpose of this form is to control access to the base. It is important that Security Forces knows where everyone is working so pass/badge can be issued correctly.

JB CHS-AB/WS Contract Security Form 74, Rev. 23 October 2013 This Form is Subject to the Privacy Act of 1974, 5 U.S.C. 552A Controlled Unclassified Information (CUI)

APPLICATION FOR PERSONNEL TO WORK UNDER DEPARTMENT OF DEFENSE CONTRACT ON JOINT BASE CHARLESTON (JBC)

APPLICATION FOR PERSONNEL TO WORK UNDER DEPARTMENT OF DEFENSE CONTRACT ON JOINT BASE CHARLESTON (JBC) NOTE: AFTER BASE SPONSOR SIGNS, ORIGINAL MUST BE HAND CARRIED TO THE SECURITY FORCES PASS & REGISTRATION SECTION BLDG 1953 (VCC). THE ORIGINAL IS KEPT AT THE 628th SECURITY FORCES CONTRACT SECURITY SECTION (628 SFS/S5X). INSTRUCTIONS FOR COMPLETING THIS FORM ARE ON THE REVERSE SIDE.

Instructions/Guidelines for the SFS Form 74:

Section 1: (Fill in all information)

#1 COMPANY/VENDOR NAME: If the company is a (sub) also include the primary company’s name. (i.e. If the Sub is Coke, then the Primary is DECA)

#10 LOCATION OF WORK: [JBC-AB Area 1 Main Base – Area 2 Hunley Park ] [JBC-WS Area 3 Main Base ] [ JBC-AB Area 4 Flight line ( Aircraft Parking Ramp) – Area IMC ( Industrial Maintenance Complex) ] [JBC-WS Area 6 East Side Ord – Area 7 North Side Ord - Area 8 WHARF Alpha – Pier - Area 9 Bravo – Pier - Area10 Charlie – Area 13 TC Dock – Area 14 Traffic Control [ECP 19-TCI]

NOTE: Badge issued for Contractor to work in Area 4 and the IMC, will have a “RED” back ground.

#14 BASE SPONSOR CONTACT INFO: This is the person that signs the form at the bottom as the base sponsor (#14 & # 25 are the same). Must have a signature letter on file to sign this areas.

Section 2: (Fill in all information) NOTE: All the information is important and must be correct.

#16/17 If you are not a U.S. citizen, you MUST provide: copy of a state driver’s license/state issued photo ID; Social Security Card (SSN); Permanent resident card or Alien Registration Receipt Card (Form 1-551); INS Form I- 9, and a If you are a Foreign Born Naturalized U.S. Citizen, “YOU MUST” provide INS Form I-9 and Certificate of Naturalization.

#18 JOB SITE VERIFYING OFFICIAL: This is person to be contacted to verify anyone attempting to gain access for support of contract/job site (i.e. material/equipment deliveries). Supervisor Badge.

#19 INDUSTRIAL MAINTENANCE COMPLEX/FLIGHTLINE RESTRICTED AREA 4: This is the area that requires you to enter through the access gates and doorways along the flight line. The controlled area consists of the flight line, buildings, and activities that support, maintain and secure the aircraft. Access is controlled through buildings along the perimeter and the vehicle and pedestrian gates. If working within this area mark “YES” for issuance of a badge that allows you access to this area.

#20 When answering the FELONY question, be honest! If the NCIC investigation produces a positive finding and you answered “NO”, your integrity will be questioned which will/can lead to denial of installation access. Any individual convicted of a felony to include but not limited to: murder, assault with intent to commit murder, rape, extortion, robbery, armed robbery, or any drug offense may be denied access to the installation. In addition, any individual currently on parole, probation or on the Sex Offender Registry will be denied access to the installation. __________Int.

Section 3: (Fill in all information)

#23 EMPLOYMENT SUPERVISOR: Your job site/contractor supervisor/superintendent for whom you work for

#24 BASE SPONSOR: A DoD or military approving agency, to include Units that can verify a need for installation access for the purpose of a job/contract (i.e. Contracting Office, DECA, CES, Army Corps of Engineers, etc).

Must have signature letter on file to sign this area. Note: (BOTH SIGNATURE ARE REQUIRED FOR JB CHS-AB/WS)

HOW LONG DOES IT TAKE

You do not get the form back once it has been turned into the SFS VCC. The form normally takes 72-hours to process and sometimes longer if discrepancies are found. We appreciate your patience as we work to secure Joint Base Charleston.

CONTRACTOR PASS PROCEDURES

(a) Once the contracting company hires the individual, the individual will be required to fill out all information on the front of this form, so he or she can obtain a pass. It is the responsibility of the company requesting the contractor pass to verify the validity of the employee’s driver license and legal status prior to the request being submitted. Any individual operating a vehicle on the installation must insure that it meets the minimum insurance requirements for the installation and the state of South Carolina. The issuance of a pass is a privilege, which can be withdrawn, and the individual can be barred from base for noncompliance with Joint Base Charleston policies and or USAF directives. This pass must be in the possession of the contractor at all times while on the installation. Contractor pass must be visible on the employee at all times.

(b) When reporting to the Pass & Registration office to obtain an identification badge, each employee will present a valid driver’s license or state issued picture identification. NOTE: In some cases a Social Security Card may be required.

(c) The pass does not allow family members or friends to be sponsored on the installation at any time. In cases when family or friends must drive the contractor to the base, the drop off point is at the base entry gates. Employees are responsible for their own transportation to the job site.

(d) If the contractor terminates an employee, the contractor will confiscate the employee pass and returned it to Contract Security in Bldg. 1953 (VCC).

(e) Placing Job ads in the newspapers such as “Respond to the base for information, interviews, or employment,” is strictly prohibited. Companies are required to conduct their interviews and employee hiring off base.

(f) Upon completion or termination of the contract or expiration of the identification passes, the prime contractor shall ensure that all base identification passes issued to employees and subcontractor employees are returned to the issuing office, Security Forces in Bldg. 1953, Visitors Control Center (VCC) (g) Failure to comply with these requirements may result in withholding of final payment.

JB CHS-AB/WS Contract Security Form 74, Rev. 23 October 2013 This Form is Subject to the Privacy Act of 1974, 5 U.S.C. 552A Controlled Unclassified Information (CUI)