NEW FORM 300.pdf

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Attached to
INDUSTRY DAY SITE VISIT on 14 and 15 May 2025 for the Above Ground Construction Services Contract (CSC) pre solicitation
Solicitation number
HDTRA225RE0010004
Issued by

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The document is a White Sands Missile Range Installation Access NCIC-III Check Request form, prescribed under Army Regulation 190-13 by the Directorate of Emergency Services-Physical Security. The form is designed to determine an individual's suitability for accessing White Sands Missile Range through a criminal history record check. The specific form shown is partially completed, with a sponsor from the Defense Threat Reduction Agency (DTRA), LT Elisabeth C McClung, providing contact information (phone: (505) 353-4040, email: elisabeth.c.mcclung.mil@mail.mil). The form requires detailed personal information including legal name, driver's license details, access dates, and work hours, with the completed form to be submitted to a physical security email address for processing.

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Other files

File Type Posted
FORM 301.pdf PDF
Amend 0001 HDTRA225RE001 RFP 23APR2025.pdf PDF
Amend 0001 Industry Day Agenda Overview and Access on 14MAY 2025.pdf PDF
Visitor-Prenotification-Form.pdf PDF

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White Sands Missile Range Installation Access NCIC-III Check Request Prescribing Regulation: Army Regulation 190-13

Proponent: Directorate of Emergency Services-Physical Security Privacy Act Statement

AUTHORITY: 10 U.S.C. 3013; 44 U.S.C. 3103; and Army Regulation 190-13, Army Physical Security Program.

PRINCIPAL PURPOSE: To determine suitability of individual(s) requesting access to White Sands Missile Range. This information will be used to generate state and federal criminal history record checks.

ROUTINE USE(S): Personal information may be disclosed to appropriate military and civilian emergency and investigation agencies to assist in determining suitability for access to White Sands Missile Range.

DISCLOSURE: Voluntary. However, failure to provide information could result in the refusal to access White Sands Missile Range.

Legal Name as Appears on Driver’s License or State

ID.

Example: John Robert Doe

M 15-APR-75 D01234567 NM 08-AUG-24 09-AUG-24 MON-FRI

0700-1600 BLDG 465 PDC DES PS USE

ONLY

Last Name First Name Middle

Name or NA if none

Sex

(M/F) DOB

Driver’s License Number

Driver’s License

State Begin Date End Date

Work Access Hours

Work Area/ Visit

Location Org.

Name

Clear/Denied/

NMI

(DES PS USE

ONLY)

Sponsor Phone: Sponsor Email:

Purpose for access:

Sponsor Name:

Sponsor Organization: Sponsor Signature:

When complete submit to: usarmy.wsmr.imcom.mbx.physical-security@army.mil (DES USE ONLY) NCIC-III Check Date NCIC-III Check Complete

Remarks Block: please ensure all fields below are filled out in their entirety.

** Note: If access to WSMR is for contract purpose, Sponsor will be the COR.

WSMR FORM 300 March 2025

Last NameRow1:
First NameRow1:
Middle Name or NA if noneRow1:
Drivers License NumberRow1:
Drivers License StateRow1:
Work Access HoursRow1:
Work Area Visit LocationRow1:
Org NameRow1:
Last NameRow2:
First NameRow2:
Middle Name or NA if noneRow2:
Drivers License NumberRow2:
Drivers License StateRow2:
Work Access HoursRow2:
Work Area Visit LocationRow2:
Org NameRow2:
Last NameRow3:
First NameRow3:
Middle Name or NA if noneRow3:
Drivers License NumberRow3:
Drivers License StateRow3:
Work Access HoursRow3:
Work Area Visit LocationRow3:
Org NameRow3:
Last NameRow4:
First NameRow4:
Middle Name or NA if noneRow4:
Drivers License NumberRow4:
Drivers License StateRow4:
Work Access HoursRow4:
Work Area Visit LocationRow4:
Org NameRow4:
Last NameRow5:
First NameRow5:
Middle Name or NA if noneRow5:
Drivers License NumberRow5:
Drivers License StateRow5:
Work Access HoursRow5:
Work Area Visit LocationRow5:
Org NameRow5:
Last NameRow6:
First NameRow6:
Middle Name or NA if noneRow6:
Drivers License NumberRow6:
Drivers License StateRow6:
Work Access HoursRow6:
Work Area Visit LocationRow6:
Org NameRow6:
Last NameRow7:
First NameRow7:
Middle Name or NA if noneRow7:
Drivers License NumberRow7:
Drivers License StateRow7:
Work Access HoursRow7:
Work Area Visit LocationRow7:
Org NameRow7:
Last NameRow8:
First NameRow8:
Middle Name or NA if noneRow8:
Drivers License NumberRow8:
Drivers License StateRow8:
Work Access HoursRow8:
Work Area Visit LocationRow8:
Org NameRow8:
Last NameRow9:
First NameRow9:
Middle Name or NA if noneRow9:
Drivers License NumberRow9:
Drivers License StateRow9:
Work Access HoursRow9:
Work Area Visit LocationRow9:
Org NameRow9:
Last NameRow10:
First NameRow10:
Middle Name or NA if noneRow10:
Drivers License NumberRow10:
Drivers License StateRow10:
Work Access HoursRow10:
Work Area Visit LocationRow10:
Org NameRow10:
Last NameRow11:
First NameRow11:
Middle Name or NA if noneRow11:
Drivers License NumberRow11:
Drivers License StateRow11:
Work Access HoursRow11:
Work Area Visit LocationRow11:
Org NameRow11:
Last NameRow12:
First NameRow12:
Middle Name or NA if noneRow12:
Drivers License NumberRow12:
Drivers License StateRow12:
Work Access HoursRow12:
Work Area Visit LocationRow12:
Org NameRow12:
Check Box7: Off
Date8_af_date:
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Date4_af_date:
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Begin Date Row 1:
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End Date Row 1:
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Text8:
Text9: LT ELisabeth C McClung
Text10: 505-353-4040
Text11: elisabeth.c.mcclung.mil@mail.mil
Text12: DTRA

File details come from the government source that posted it. Updated .