SFS_FORM_31 V8 BADGING FORM.pdf

SFS FORM 31, 20180604

CONTRACTOR/VISITOR AFFIDAVIT BADGE APPLICATION FOR UNESCORTED

ENTRY ONTO 109TH AIRLIFT WING

SECTION I: Contractor/Visitor must ensure all blocks are complete

NAME (First, Last, M.I.): ADDRESS: (Contractor/Visitor Home of Record and Phone)

COMPANY NAME/ADDRESS/PHONE

NUMBER:

IF SUB-CONTRACTOR,

PRIME COMPANY NAME/PHONE

NUMBER:

REASON FOR ACCESS:

GENDER SOCIAL SECURITY #

DATE OF

BIRTH

STATE DRIVER

LIC# AND STATE

CITIZENSHIP RACE

HAIR

COLOR

EYE

COLOR

HEIGHT WEIGHT

THIS AFFIDAVIT CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED STATES CODE, SECTION 1001 OR OTHER APPLICABLE LAWS AND REGULATIONS.

BY SIGNING BELOW, YOU AGREE TO SUBMIT TO A CRIMINAL BACKGROUD CHECK. IF “YOU”, THE APPLICANT, IS FOUND TO HAVE BEEN CONVICTED FOR ANY OF THE FOLLOWING OFFENSES LISTED BELOW, AS DEFINED IN THE NEW YORK STATE PENAL LAW/AFMAN 31-113, YOU WILL NOT BE GRANTED ACCESS TO THE INSTALLATION FOR THE PURPOSE OF EMPLOYMENT/ACCESS. THE INSTALLATION COMMANDER HAS THE INHERANT RIGHT TO DENY ACCESS AT ANY TIME. IF DISQUALIFING INFORMATION IS REVEALED ON AN APPLICANT WHO HAS ALREADY BEEN ISSUED A TEMPORARY ACCESS CREDENTIAL, THE INSTALLATION COMMANDER WILL DETERMINE WHETHER CONTINUED UNESCORTED ACCESS WILL BE GRANTED BASED UPON THE NEW INFORMATION. UNTIL THIS DETERMINATION IS MADE, THE PERSON’S UNESCORTED ACCESS

TO THE INSTALLATION WILL BE DENIED:

- ANY CHARGES RELATED TO TERRORISM

- UNABLE TO VERIFY CLAIMED IDENTITY

- HAVE BEEN PREVIOUSLY BARRED FROM DOD INSTALLATIONS

- ANY ACTIVE WANTS AND WARRANTS FROM ANY JURISDICTION

- ESPIONAGE, TREASON, SABOTAGE, TERRORISM, MURDER AND/OR ACTS TO OVERTHROW US GOVERNMENT

- FEDERAL OR STATE AGENCY’S WATCH LIST OR HIT LIST FOR CRIMINAL BEHAVIOR OR TERRORIST ACTIVITY

- FIRE ARMS/EXPLOSIVE VIOLATIONS

- SEXUAL ASSAULT

- ARMED ROBBERY

- RAPE

- CHILD MOLESTATION/CHILD PORNOGRAPHY

- TRAFFICING HUMANS

- DRUG POSSESSION WITH INTENT TO SELL/DRUG DISTRIBUTION

- MANSLAUGHTER

- BURGLARY

PLEASE READ ABOVE BEFORE SIGNING

EMPLOYEE SIGNATURE: ____________________________________________________ DATE: ___________

By signing this application you agree to submit to a criminal background check.

ALL PROSPECTIVE CONTRACTORS MUST BE U.S. CITIZENS OR MUST HAVE ESTABLISHED AND MAINTAIN LEGAL RESIDENCE IN THE U.S., AND ARE AUTHORIZED BY THE US GOVERNMENT TO WORK IN THE UNITED STATES (I.E. GREEN CARD, WORKER AUTHORIZATION, ETC.).

NOTE: VISITORS/CONTRACTORS SHALL RETURN BADGE TO SF PASS & ID UPON

EXPIRATION OR TERMINATION OF CONTRACT. VISTORS/CONTRACTORS WILL

HAVE THE BADGE ON THEM AT ALL TIMES - NO EXCEPTIONS!!!!

SECTION II: To be completed by Contracting Office/Sponsoring Activity

THIS IS TO CERTIFY: I have verified that the individual above has a “need” to be on the Installation and requires a visitor’s badge. I also understand that I, the Sponsor, take full responsibility for the actions of the individual applying for access.

NAME/PHONE # SPONSOR: _____________________________________________________________________

SPONSOR SIGNATURE: ____________________________________________________ DATE: ___________

FPCON NORMAL- BRAVO ACCESS ONLY

Hours of operation will only be from 0700 -1600, Monday through Friday. Weekend and Holidays only if requested.

SECTION III: To be completed by Security Forces Pass and ID

NCIC Check Date: Date Issued (YYYYMMDD) Date Expires (YYYYMMDD)

PRIVACY ACT STATEMENT

AUTHORITY: Section 3101, Title 44, United States Code, AFI 33-332, 5 USC 552A PRINCIPAL PURPOSE(S): The purpose for requesting personal information is to assist security personnel in developing records to document contractor/visitor suitability for access to Stratton Air National Guard Base ANGB. The Social Security Number (SSN) and Date of Birth (DOB) are necessary to identify the person and records. This information may be used to determine suitability of persons desiring access to Stratton ANGB as well as for other lawful purposes including law enforcement and litigation. INTENDED USE: All contractors, subcontractors, unit’s or Stratton ANGB sponsoring activities who have employees not authorized a Common Access Card and require regular and frequent access to Stratton ANGB in performance of their official duties. DISCLOSURE: Disclosure of requested information is mandatory. Failure to provide information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the Air Force contract while serving in the capacity of prime contractor or subcontractor/supplier employee.

*EXTENSIONS

NCIC Check Date: Date Issued (YYYYMMDD) Date Expires (YYYYMMDD)