Appendix_B_-_Qatar_Base_Access_Information.pdf

APPENDIX B -

Qatar Base Access

Information

Current Badge Expiration:________

ASG-QA BADGE REQUEST OCN Number__________

OTHER COUNTRY NATIONAL (OCN) EMPLOYEES PRIVILEGE & ACCESS JUSTIFICATION FORM (1 of 2 pages)

SECTION 1: To be completed by Supervisor of Organization (ALL AREAS MUST BE FILLED IN)

(Failure to properly fill out this form will result in rejection of request)

1) U.S. ORGANIZATION REQUESTING PRIVILEGE/ACCESS: ,

A) COR requesting OCN Privilege/Access: (Name, Rank, Bldg #):_____________________________________

B) COR Phone DSN Number/Cell:___________________ Email:

2) COMPANY NAME (INCLUDING ALL SUBCONTRACTS):

A) Supervisor Name and Phone #:

B) Contract Number and Contract End Date:

3) OCN EMPLOYEE’S NAME (Last, First, Middle):

A) Nationality:

B) Date (DDMonthYYYY) and Place of Birth:

C) Passport Number:_________________________ Previous Passport #__________________________________

D) Passport issued by (Country): _____________Date of Issue:___________ Date of Expiration:________________

E) OCN Phone Number (NOT the supervisor’s or CAS number): Cell:_____________ Residence:_____________

4) JOB TITLE AND DESCRIPTION (OCN Employees): ____________________________ Time on CAS:_________

5) WORK LOCATION(S), PER LOA: CAS: ____Falcon 78: ____CAS South: ____

A) Building Numbers:_______________________________ Work Areas:___________________________________

6) REQUEST ADDITIONAL (Not in LOA) AUTHORIZATION FOR NON WORK RELATED PRIVILEGES:

*NOTE: MARK REQUEST WITH AN X AND JUSTIFY BELOW

A justification memo must be submitted for any privileges not specified in the LOA, with Supervisor signature and COR Stamp/Seal

DFAC____ Mil Exchange____ Mil Banking____ Post Office____ CAC____

MWR Sites: PX__ Barber/Beauty Shop___ Gyms___ Trips___ Oasis/TopOff___

*NOTE: A justification memo must be submitted for 6-8, with Supervisor signature and COR Stamp/Seal

7) REQUESTED UNESCORTED PRIVILEGE (Red Badge): Yes_____ No_____ Justification: __________________

8) REQUEST ESCORT PRIVILEGE OCN: YES___ NO___

(Must Provide Justification Memo with Badge Request Packet and on Date of Training)

9) REQUEST CELL PHONE PRIVILEGES: YES___ NO___

(Needs Installation Commanders Approval)

Cell Phone Manufacturer: Model: Cell Phone Number:

SIM Card Number: IMEI: ______________________________

10) REQUEST POV DRIVING PRIVILEGE ON CAS: Yes NO

Vehicle ID: License plate number:

Current Badge Expiration:________

ASG-QA BADGE REQUEST OCN Number__________

OTHER COUNTRY NATIONAL EMPLOYEES PRIVILEGE & ACCESS JUSTIFICATION FORM (2 of 2 pages)

SECTION 2: (ALL AREAS MUST BE FILLED IN)

OCN EMPLOYEES NAME:

*NOTE: Must be the same name located on page 1*

11) REQUEST MAGNETIC MEDIA PRIVILEGE ON CAS: Yes NO

Make/Model Serial number:

12) DIRECTORATE /COR Approval Name (Print): ________________________________________________

Date: Approval Signature: ______________________

DD/MM/YYYY

SECTION 3: To be completed by Screening Office

Name and Background Checks: Derogatory / No Derogatory Escort Privileges Verified Yes / No

Screener Signature: ___________________________Date:____________

Screener Comments: _____________________________________________________________________

SECTION 4: To be completed by PMO

Name and Bar List derogatory checks: Derogatory / No Derogatory

PM or Designee Signature: _______________________________Date: _____________

OCN Employees will be issue /granted privileges shown on back of DBIDS Card

(DBIDS/PMO AUTHORIZED PERSONNEL ONLY)

*All packets that require Exception to Policy must be approved and signed by Installation Commander.*

Installation Commander or Designee Signature: _______________________________Date:________ /////////////////////////////////// Document Supersedes all Previous 14 September 2015////////////////////////////////// allen.e.bunn Typewritten Text

ASG-QA SCREENING OFFICE

PERSONNEL SECURITY QUESTIONNAIRE

(Use additional paper if more space is required)

ALL FIELDS MUST BE FILLED OUT, OTHERWISE THE DOCUMENT COULD BE REJECTED

NAME (Last, First, Middle )

ALL PERSONAL EMAIL ADDRESSES ALL SOCIAL MEDIA USER NAMES

OTHER NAMES USED

RELIGION ALL LANGUAGES SPOKEN

COUNTRY OF CITIZENSHIP QATAR VISA NUMBER

PREVIOUS PASSPORTS (Country and Number) Country__________Nmbr___________EXP____ Country__________Nmbr___________EXP____

DATE OF BIRTH PLACE OF BIRTH

(YYYYMMDD) a. City b. County c. State d. Country New Base Access

Renewing Base Access

PHYSICAL CHARACTERISTICS (Complete all blocks – use pounds and inches) LANDLINE NUMBER (Residence):

a. Gender

b. Race

c. Height (Ft, In)

d. Weight (Lbs)

e. Hair Color

f. Eye Color

ALL PERSONAL CELL NUMBERS:

RESIDENTIAL ADDRESS IN QATAR: ______Live Out ______Accomodation (Check X for what applies)

LIST ALL CURRENT ROOMMATES AND THEIR PHONE NUMBERS:

Name:_____________________________ Phone Number:_________________ Name:________________________ Phone Number:__________________ Name:_____________________________ Phone Number:_________________ Name:________________________ Phone Number:__________________ Name:_____________________________ Phone Number:_________________ Name:________________________ Phone Number:__________________

FULL AND PART TIME EDUCATION (List in chronological order, including part-time attendance, beginning with the last school attended.)

a. Dates (YYMM)

(1) From (2) To

b. Name of School c. Address (City, Province, Country) d. Major e. Degree Earned

FOREIGN TRAVEL (From birth until present, whether for work or vacation) :

List All Passport Numbers and Country of Issue:

Dates (YYMM) Country Address Where Stayed Purpose of Travel Who visited

EMPLOYMENT (List ALL employment, self-employment, and part-time employment, from birth until present)

Yes No

Have you ever worked for a Government?

a. Dates (YYMM) b. Name of Employer c. Job Site / Location d. Immediate Supervisor

(2) Telephone No.

(Include Country Code)

(1) From (2) To (Street, City, State and Zip Code) (1) Name (2) Telephone No. (Include Country Code)

FAMILY / ASSOCIATES Give data for all: Father, Mother, Spouse, Cohabitant, and Children

All brothers and sisters

a. Relationship and Name (LAST, First, Middle Initial)

b. Present Address (Street, City, State and Zip Code and Phone Number)

c. Date of Birth

(YYMMDD)

d. Place of Birth (City, State, Country)

e. Citizenship f. Occupation

(1) Father

(2) Mother

(3) Spouse (Maiden Name if applicable)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

a. Current Marital Status (X one)

(1) Married

(2) Never Married

(3) Legally Separated

(4) Divorced (5) Widowed

MILITARY SERVICE:

Organization Dates of Service

MMYYYY - MMYYYY

Volunteer/

Conscripted

Occupation Supervisor Name Supervisor Phone Number allen.e.bunn Typewritten Text allen.e.bunn Typewritten Text

Financial

Yes No (“Yes” answers must be explained)

Do you have any outstanding financial obligations?

Have you ever had financial problems due to gambling, drug abuse or alcoholism?

Do you have an income source other than your current employer?

Debts

(1) Creditor (2) Amount Owed (3) Property Type Involved (4)_Delinquent (Yes/No)

ORGANIZATIONS

Are you now or have you ever been affiliated with any organization, association, movement, group, or combination of persons which advocates the overthrow of a government?

Have you ever been a member of any organization or activity which advocates violence, the threat of violence or use of force to achieve its goals?

Do you have family ties to anyone who belongs to or supports any organization or activity which advocates violence, the threat of violence or use of force to achieve its goals?

List all organizations (Social AND Official) in which you hold or have held membership since age 16.

(1) Name (Do not abbreviate) (2) Address (Number and Street, City, State, Zip Code) (3) Type (4) From (YYMM) (5) To (YYMM)

CHARACTER REFERENCES (List 5 good friends, colleagues, classmates, etc., who together have known you for the last five years. Do not list anyone who is listed elsewhere on this form). Failure To Provide References Will Result In The Rejection Of Your Request

a. Dates (YYMM) b. Name (LAST, First, Middle Initial) d. Address (Number and Street, Apt e. Telephone No. (Include Country Code)

f. Occupation

(1) From (2) To c. Association (Friend, etc.) No., City, State, and Zip Code) (1) Home (2) Cell

ARRESTS You must list ALL arrest information regardless of whether you have previously listed or disclosed this information You may exclude minor traffic violations for which a fine or forfeiture of $100 or less was imposed, unless alcohol or drug related.

Yes No

a. Have you ever been arrested, charged, cited, held, or detained by law enforcement or juvenile authorities regardless of whether the charge was dropped or dismissed or you were found not guilty?

b. Do you, your relatives, or your associates have any current or previous affiliation with any form of organized crime or criminal activity?

If YES, what is the name of the organization?_______________________________________________________________________

List details of “Yes” answers to question a.

(1) Date

(YYMMDD)

(2) Nature of Offense or violation (3) Name and Location of Law Enforcement Agency (City and State)

(4) Name and Location of Court Magistrate City and Country)

(5) Penalty Imposed or Other Disposition in Each Case

DRUG / ALCOHOL USE AND MENTAL HEALTH

a. Have you ever tried, used or possessed any illegal drugs?

b. Have you ever been involved in the illegal purchase, manufacture, or sale of any illegal drugs?

c. Have you ever misused or abused any drug prescribed by a licensed physician for yourself or for someone else?

d. Has your use of alcoholic beverages (such as liquor, beer, wine) ever resulted in the loss of a job, disciplinary action, arrest by police, or any alcohol-related treatment or counseling (such as for alcohol abuse or alcoholism)?

e. Have you ever been treated for a mental, emotional, psychological, or personality disorder/condition/problem?

ORGANIZATION YOURSELF RELATIVE/ASSOCIATE

CERTIFICATION. I certify that the entries made by me are true, complete, and accurate to the best of my knowledge and belief and are made in good faith. I understand that any knowing and willful false statement on this form can have an adverse impact on whether I will be granted base access.

a. Typed Name (LAST, First, Middle Initial)

b. Passport No

c. Signature

d. Date Signed (YYMMDD)

INSERT QID AS PDF

FILE HERE AND THEN

DELETE THIS PAGE

INSERT PASSPORT PAGES

WITH STAMPS AND TEXT HERE

AS PDF FILE AND THEN DELETE

THIS PAGE

INSERT MISSED APPOINTMENT MEMOS, LOA, OR

JUSTIFICATION AS APPROPRIATE HERE AS A PDF

FILE AND THEN DELETE THIS PAGE

IF THIS PAGE IS NOT NECESSARY, THEN DELETE IT