NVARNG Personal Security Questionnaire~2.docx
DOCX document 22 KB Posted
- Attached to
- Youth ChalleNGe Food Service
- Solicitation number
- 43ADG-S2248
- Issued by
- Elko County, Nevada
About this file
The document is a Personal Security Questionnaire for the Nevada Army National Guard (NVARNG). It requires individuals to provide personal information, such as name, date of birth, social security number, driver's license details, and employment information, as well as answer questions about their citizenship, criminal history, and security clearances. The purpose is to allow the NVARNG Provost Marshal and local commands to perform a local/national security check on the individual as required.
The related state and local contract opportunity is for a Food Service Management Company (FSMC) to operate the National School Lunch Program (NSLP), School Breakfast Program (SBP), and the After School Care Snack Program (ASCS) at the Carlin location in the state of Nevada. The contract will be for a four-year period and is being sought by the State of Nevada Purchasing Division on behalf of the Office of the Military Battle Born Youth ChalleNGe Academy (BBYCA).
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Text version
NVARNG PERSONAL SECURITY QUESTIONNAIRE
1. Name: ________________, ________________, _________________ Last First Middle (full name)
2. Date of Birth: __________________________ (Month Day, Year)
3. Social Security Number: _________ - ______ - _________
4. Sex: MALE____FEMALE___
5. Driver’s License Number______________________________________
6. Driver’s License State of Issue_________________________________
7. Home Address_____________________________________________
8. City______________________________________________________
9. State_____________________________________________________
10. Place of Birth:__________________________ (City, State, Zip, Country)
11. Employer/Command:________________________________________
12. Phone Numbers: Employer (____) ____-____ Home (____) ____-____
| YES |
| NO |
| NA |
Are you a U.S. Citizen?
Are you a legal resident alien?
Have you ever been barred from any federal government facility or base?
Have you ever been convicted of a felony?
Do you have any outstanding warrants or are you a fugitive from justice?
Are you currently pending trial?
Are you on an approved Dept. of Prisons program? (probation, parole, work release etc.)
Have you ever been convicted on a weapons charge or Theft
13. Individual Requesting Access. I certify that the above information is correct and I agree to allow NVARNG Provost Marshal and/or local commands to perform a local/national security check on me as required.
Signature: ________________________Date:_________________
14. Employer Supervisor/Manager. I certify that the above information has been verified with the individual’s documents; to include a United States issued birth certificate and a United States issued picture identification (e.g., driver’s license, U.S. military ID, Resident Alien Registration Card, Foreign Passport, Foreign Military ID etc.)
Signature: __________________________Date:_________________
15. FMO/NVNG Representative – Print Name_______________________
Signature: __________________________Date:_________________
Project:________________________Location:_________________________
Contract start date:_______________Contract end date:__________________
ANNEX D
Appendix 3
TAB 3
File details come from the government source that posted it. Updated .