NCIC Screening and Pass Request - Template.pdf

PDF 205 KB Posted

Attached to
Replacement of B583 Degraded and Obsolete Controllers Federal contract opportunity
Solicitation number
FA460025Q0009
Issued by
Department of the Air Force Air Combat Command

About this file

Written by GovTribe AI ·

This is a template form titled "55 SFS CONTRACTOR/VENDOR NCIC SCREENING & PASS REQUEST SPREADSHEET" used for requesting access to Offutt Air Force Base for contractors and vendors. The form collects personally identifiable information (PII) including full name, date of birth, driver's license/ID number, state, social security number, work schedule details, and citizenship status of personnel requiring base access.

The spreadsheet template includes fields for company information (name, address, representative details), base sponsor information, and contract details. The form requires signature blocks for the Unit Commander or Security Manager, with an additional signature requirement from 55 WG/IP for non-U.S. visitors. Personnel must present REAL ID ACT compliant identification or approved alternate photo ID at the Visitor Control Center. The collection of this information is authorized under 10 U.S.C. 8013 and DoD 5200.2R, with access restricted to personnel responsible for contract administration.

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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

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