Attachment 003 - 190-17 Restricted Area - Proximity Badge Request (01 Jun 22).pdf

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Attached to
PBA Server Room HVAC
Solicitation number
W519TC-24-Q-2369
Issued by

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This document is a Restricted Area / Proximity Badge Request form for access to the Pine Bluff Arsenal (PBA) facility. The form collects personal information such as the requestor's name, citizenship status, date of birth, and contact details. It also requires information about the specific access area and authorizing official signatures. This form is used to support the Army's physical security and access control programs and ensure proper identification of personnel authorized access to restricted areas at PBA.

The related federal contract opportunity is for the procurement of two packaged HVAC heat pump units for the PBA server room. This is a firm-fixed-price purchase order contract with a 120-day delivery requirement after award. It is a total small business set-aside solicitation under NAICS code 339999 with a size standard of 550 employees. The contracting agency is the Department of the Army Materiel Command Contracting Command Rock Island Arsenal.

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Other files

File Type Posted
B08 - Amendment 03 W519TC24Q2369.pdf PDF
B08 - Attachment 001 - PRICE MATRIX REVISED.xlsx XLSX spreadsheet
Attachment 002 - Revised Purchase Requirements Server Room HVAC Units 5SEP2024.pdf PDF
B08 - Amendment 02 W519TC24Q2369.pdf PDF
W519TC-24-Q-2369 Amendment 01 - Site Visit.pdf PDF
Attachment 002 - 190-5 Access Control Background Check Form (01 Jun 22).pdf PDF
RFQ W519TC24Q2369.pdf PDF
Attachment 001 - PRICE MATRIX.XLSX XLSX spreadsheet

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FOR VCC USE ONLY

CUI

RESTRICTED AREA / PROXIMITY BADGE REQUEST

M.I.:FIRST:LAST: _____________________________________ _________________________________ ________ SUFFIX: _______

DIRECTORATE / ORGANIZATION / COMPANY: ___________________________________________________________________________

) U.S. CITIZEN: YES NO (IF NO – PERM. RES CARD OR FN SCREEN EXP DATE: _____________________________

DOB: _____SEX: ___HEIGHT (ft & in): _____ EYES: _______HAIR: _____________ ______ ________ _____ _________________

ADDRESS: ________________________________________CITY___________________________________STATE_______ZIP_________

PERSONAL PHONE: _________________________________________ WORK PHONE: _______________________________________

NOTE: ALL BADGES/PASSES MUST BE TURNED IN OR RENEWED BY THEIR EXPIRATION DATE.

DATE: SIGNATURE: ________________________________________________________________________ ______________________

FOR QEF ACCESS PURPOSES ONLY

AREA: ADMIN TELE TLW

AUTHORIZING OFFICIAL: __________________________________________ SIGNATURE: ____________________________________

FOR WATER TREATMENT FACILITY ACCESS PURPOSES ONLY

AUTHORIZING OFFICIAL: __________________________________________ SIGNATURE: ____________________________________

VALID PHOTO ID VERIFICATION

TYPE: ________________________________ #: ________________________________________ EXP DATE: ____________________

PBA/NAF EMPL

PBA RESTRICTED AREA BADGE INFORMATION

CONTRACTOR VISITOR

Controlled By: DES CUI Category: PRVCY

LDC: FED ONLY

POC: Shannon Stowell; 870-540-4080

PBA FORM 190-17 CUI 01 JUN 2022

BADGE # ISSUE DATE ACCESS ESCORT TYPE EXPIRE DATE SPONSOR

PRIVACY ACT STATEMENT:

AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; Army Regulation 190-13, The Army Physical Security Program; 10 U.S.C. 1124 and 5 U.S.C. 4502.

PRINCIPAL PURPOSE(S): To support Department of the Army physical security and access control programs; Information Assurance program; to record personal data and vehicle information registered with the Department of the Army; to provide a record of security/access badges issued; to restrict entry to installations and activities; to ensure positive identification of personnel authorized access to restricted areas; to maintain accountability for issuance and disposition of security/access badges and for producing installation management reports.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:

The DoD 'Blanket Routine Uses' also apply to this system of records.

DISCLOSURE: Disclosure is voluntary. However, failure to provide this information may result in denial of entry to Pine Bluff Arsenal.

For additional information regarding privacy practices see System Of Record Notice (SORN) A0191-13 OPMG at http://dpcld.defense.gov/Privacy/

SORNsIndex/DOD-wide-SORN-Article-View/Article/569989/a0190-13-opmg/ http://dpcld.defense.gov/Privacy/

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