NCIC Screening Pass Request.pdf

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Unaccompanied Housing Washer Dryer Lease
Solicitation number
FA460025Q0012
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This is a contractor/vendor NCIC screening and pass request spreadsheet form used by the 55th Security Forces Squadron (SFS) at Offutt Air Force Base for processing base access requests. The form is used to collect personal identifying information (PII) from contractors and vendors who need access to the installation.

The spreadsheet requires detailed information including full name, date of birth, driver's license/ID number, state, social security number, work schedule details (days/hours), contract dates, and citizenship status for each individual needing access. The form notes that all personnel must present a REAL ID ACT compliant driver's license, state ID, or approved alternate photo identification when arriving at the Offutt AFB Visitor Control Center. For non-U.S. visitors, additional approval is required via a 55 WG/IP signature block. The form includes privacy act information stating that collection is authorized under 10 U.S.C. 8013 and related DoD regulations, with access restricted to personnel responsible for contract administration or official DoD duties.

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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.

1454503194A Cross-Out

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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Company Rep Name:
Company Phone Number:
Sponsoring Squadron:
Sponsor's Name:
Sponsor's Phone Number:
Request Date:
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