2_-_Personal_Data_Questionnaire_Form_380-2.pdf

(See AR 380-67 for use of this form; proponent is SIOAN-LE)PERSONAL DATA QUESTIONNAIRE - WORK PHONECONTRACTOR COMPANY NAME (Prime)

CONTRACT EXPIRESSUBCONTRACTOR NAME CONTRACT NUMBER

SSNINDIVIDUAL'S NAME (First name, Middle name, Last name) ****** NO INITIALS ******

OTHER NAMES USED (INCLUDE FORMER MARRIED NAMES) TYPE BADGE/AREA:

DATE OF BIRTH PLACE OF BIRTH CITIZENSHIP

MONTH DAY YEAR CITY COUNTY STATE

*** NOTE *** IF YOU WERE BORN OUTSIDE OF THE UNITED STATES, YOU MUST FURNISH PROOF OF U.S.

CITIZENSHIP UPON SUBMISSION OF THIS FORM TO THIS INSTALLATION. PROOF OF U.S. CITIZENSHIP MUST BE SUBMITTED IN PERSON BY THE INDIVIDUAL, ALONG WITH THIS FORM, TO THE OPERATIONS OFFICE, SECURITY

MANAGEMENT DIVISION, DLES, LOCATED IN ROOM 10, BUILDING 53.

COLOR EYES COLOR HAIR HEIGHT WEIGHT SEX RACE

PHYSICAL DESCRIPTION

DRIVERS LICENSE NO. STATE OF ISSUE STATE IDENTIFICATION NO. STATE OF ISSUEO

R

ADDRESSES FOR THE PAST FIVE (5) YEARS, INCLUDING PRESENT ADDRESS: (STREET, CITY, COUNTY, STATE)

1. 4.

2. 5.

3. 6.

AUTHORITY: Internal Security Act of 1950 (50 USC 797); Executive Order 9397. PRINCIPAL PURPOSE: To document information necessary for selection, assignment or termination for persons desiring entry to all, or parts, of Anniston Army Depot or other military installations.

ROUTINE USES: The information provided will be furnished to the Directorate of Law Enforcement and Security at Anniston Army Depot; to officials within the Department of Defense who have a need for it to perform official business; and to Federal, State, or local agencies that maintain civil, criminal, or law enforcement information. NATURE OF DISCLOSURE: Disclosure of the requested information is voluntary.

DATELEGAL SIGNATURE OF INDIVIDUAL REQUESTING ACCESS:

************************ CERTIFICATION ************************

I certify that the individual named above is, in fact, an employee of the company as listed above. I understand that a knowing and willful false statement can be punished by fine or imprisonment, or both. (U.S. Code, Title 18 USC 1001)

DATESIGNATURE OF AUTHORIZED PERSONNEL/REPRESENTATIVE

DO NOT WRITE BELOW THIS LINE

DATESIGNATURE OF DISAPPROVING OFFICIAL

DISAPPROVED

APPROVED

NO DRIVING PRIVILEGES

PHOTOGRAPHIC BADGE

NON-PHOTOGRAPHIC BADGE - NO ESCORT

Have individual report to the DLES-SM-0 PRIOR to issuance of a badge.NON-PHOTOGRAPHIC BADGE - ESCORT REQUIRED

SIGNATURE OF APPROVING OFFICIAL DATE

PREVIOUS EDITIONS OBSOLETESIOAN Form 380-2, Rev 31 Aug 99