NCIC Screening and Pass Request.pdf

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B301 HVAC System Controller
Solicitation number
FA460025Q0008
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This is a screening and pass request form used by the 55th Security Forces Squadron (SFS) at Offutt Air Force Base for contractor/vendor National Crime Information Center (NCIC) checks and base access. The spreadsheet template collects personally identifiable information (PII) from contractors including full name, date of birth, driver's license information, social security number, work schedule details, and citizenship status.

The form requires completion of company information (name, address, representative details), base sponsor information, and contract details. It includes a notable requirement that all personnel must present REAL ID Act compliant identification or approved alternate photo ID at the Visitor Control Center. For non-U.S. visitors, additional approval from the 55 WG/IP is required as indicated by the signature block. The form's authority derives from 10 U.S.C. 8013 and DoD security program requirements, with the information being maintained by local Security Forces while access requirements exist.

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Contract#:

Contract Start/End Dates: Unit Commander or Security Manager Sig Block

Full Name Country of Last, First, MI Year Month Day Drivers License/ID # State SSAN Days Hrs Start Date - End Date (MMDDYYYY) Citizenship

Personally Identifying Information (PII) being collected by this form is authorized for collection under provisions of 10 U.S.C. 8013, Secretary of the Air Force, DoD 5200.2R, DoD Personnel Security Program; AFI 33-202, Computer Security, Information will be maintained by local Security Forces Authority while access requirements exist. Information access is restricted to personnel responsible for contract administration, or otherwise needed in the performance of official DoD duties. Information will be properly disposed of when its required use has been concluded.

Providing this information is voluntary; however, failure to provide all of the required data shown on the spreadsheet will result in denial of entry to the installation. This information is exempt from OMB licensing under provisions of AFI 33-324, Information Collections and Reports Management Program; Controlling Internal, Public, and Interagency Air Force Collections, paragraphs 3.16.11 and 3.16.16.3.

55 SFS CONTRACTOR/VENDOR NCIC SCREENING & PASS REQUEST SPREADSHEET

Date of Birth

Offutt AFB Sponsoring Agency / Unit:

Base Sponsor's Name:

Base Sponsor's Phone #:

Request Date:

Work Schedule

Company Name:

Company Address:

Company Representative Name:

Company Representative Phone Number:

NOTE:

Security Manager will ensure all listed personnel are briefed that they must present a REAL ID ACT compliant drivers license, or state ID, or an approved alternate form of photo identification upon arrival at Offutt AFB Visitor Control Center.

Contract Start/End Dates: Unit Commander or Security Manager Sig Block 55 WG/IP Sig Block - Needed For Non U.S. Visitors

Contract Start/End Dates: Unit Commander or Security Manager Sig Block 55 WG/IP Sig Block - Needed For Non U.S. Visitors

Sheet1

Name1:
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Comapny Name:
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Sponsor's Name:
Sponsor's Phone Number:
Request Date:
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