Attachment_6_-_Public_Access_Documentation.pdf

REVISED 13JAN09/CAJ/325 SFS/PMOS

MILITARY AFFAIRS COMMITTEE BACKGROUND

AFFIDAVIT

THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974

INSTRUCTIONS

This data will be used to screen individuals who have or are seeking access to US Air Force installations or facilities controlled by the US Air Force. Please answer each question, access will be denied if this questionnaire is incomplete.

1. NAME (Last, First, Middle) 2. SEX 3. SSN 4. DATE OF BIRTH (YYYYMMDD)

5. SCARS/MARKS/TATTOOS 6. HAIR COLOR 7. EYE COLOR 8. HEIGHT 9. WEIGHT

10. ALIAS/NICKNAME 11. DRIVER LICENSE # 12. STATE

13. CURRENT ADDRESS 14. CITY 15. STATE 16. ZIP CODE 17. HOME PHONE

PLACE OF BIRTH

18. CITY YRTNUOC .12 ETATS .91

22. CITIZENSHIP 23. RESIDENT ALIEN # or IMMIGRATION DOCUMENT # and DESCRIPTION

PLEASE ANSWER THE FOLLOWING QUESTIONS

YES NO

Have you been barred from any military installation or facility?

Wanted by federal or civil law enforcement authorities, regardless of the offense/violation.

Have you been convicted of a firearms or explosives violation within the past 5 years?

Incarcerated for 12 months or longer within the past 5 years, regardless of the offense or violation.

Have you been convicted of a violent felony in the past 10 years? i.e. murder, aggravated assault, armed robbery, or rape.

Have you been convicted of a felony drug possession, possession with intent to sell/distribute within the past 10 years?

Have you been convicted of espionage, sabotage, treason, terrorism?

Convicted of any sexual crime which includes liberties with a child, rape, molestation, sexual predator, registered sex offender or sexual assault.

Name appears on any federal agency’s “watch list” or “hit list” for criminal behavior or terrorist activity.

Currently serving within the first year of parole or probation for a felony offense.

IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS PLEASE

PROVIDE AN EXPLANATION

PELICAN POINT ACCESS PASS BACKGROUND

REVISED 13JAN09/CAJ/325 SFS/PMOS

NOTE TO APPLICANT: ATTESTATION

I attest to the fact that I have been briefed by the Military Affairs Committee (MAC) Chairman and understand the purpose for the MAC background check. I understand the information on this form is being collected in accordance with 50 U.S.C., Section 797, and DoDD

5200.8 federal laws permitting the Installation Commander to limit access to the installation for security reason and that this data will be used to screen DoD contractor employees who have or are seeking access to United States Air Force installations. I have voluntarily completed this form. I understand that by signing this application, I acknowledge that I have been made aware of and have reviewed the list of Tyndall AFB disqualifying factors. I hereby give my consent and authorization for the Air Force to conduct any additional background screenings deemed necessary over the next 12 months to include comparing/checking my fingerprints against local state and federal criminal databases. The information I have provided on this application is true, complete, and correct to the best of my knowledge, and is provided in good faith. I understand that a knowing and willfully false statement provided on this application can be punished by fine or imprisonment or both (18 U.S.C. Section 1001).

Applicant Signature:__________________________________________________ Date:_______________________________

Military Affairs Committee Chairman:_____________________________________________________

PRIVACY ACT STATEMENT

AUTHORITY: Section 3101 Title 44, United States Code, AFI 33-32, 552A

PRINCIPAL PURPOSE(S): The purpose for requesting personal information is to assist security personal in documenting suitability for access to United States Air Force installations. 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 person desiring access to the installation as well as for lawful purposes including law enforcement and litigation.

INTENDED USE: For all Military Affairs Committee members who are not authorized a Common Access Card (CAC) and require regular access to the installation.

AGENCY DISCLOSURE

The public reporting burden for this collection of information is estimated to take 5 business days per response, including the timeframe for reviewing instructions, searching exiting data sources, gathering and maintaining data needed, and completing and reviewing the collected information.

PROVOST MARSHAL’S OFFICE USE ONLY

Approval/Disapproval Reason a representative of the Pelican Point Golf Course

For golfers who are not authorized a Common Access Card (CAC) and would like to utilize the golf course.