Attachment 13 - Site Visit A- KEEP Example of Package 1.pdf

This package contains

PRIVACY ACT INFORMATION

This information is

FOR OFFICIAL USE ONLY

and must be protected in accordance with the Privacy Act of 1974

Prime Contractor: Big Construction Company Contract Number: W911SF-15-D-0002 Contract Administrator: Jason L. King

Individuals' Name First MI Last Company Prime / Sub Position / Title T.O. Number Project Number Project Description

Access Required Start

Date

Access Required Stop

Date

1st Background

Check Completed Joe Bob Jones Wigets Sub Low man on totem pole 99 De12365 Repair everything 7/14/206 8/16/2017 X

CRIMINAL ANO DRIVERS HISTORY CONSENT FORM

VERY IMPCIRTANTI Please Read Privacv Act Statement and •instruction Sheet Before Comoleting This Form

PRIVACY ACT STATEMENT

AUTHORITY. I 10 U.S.C., 3013; 44 U S C 3101, AR 190-13 Chapter 8, Army Access Control

PRINCIPLE PURPOSE: To obtain information about individuals who seek access to Fort Gordon or Gillem Enclave for employment, recreation or other purposes By completing and signing this form, individual authorizes Fort Gordon or Gillem Enclave Law Enforcement officials to receive National Crime Information Center (NCIC) cnminal and dnver history ROUTINE USE: Department of Defense (DoD) Blanket Law Enforcement Routine Use. Creates record that individual gave consent for Fort Gordon or Gillem Enclave Law Enforcement Officials to obtain cnmmal and dnver history. Social Security Number (SSN), driver's license number and other documents as requested are used for 1dent1fication to retrieve 1nformat1on DISCLOSURE: Disclosure 1s voluntary Individuals, who do not disclose requested Information to include SSN, may be denied access to Fort Gordon or Gillem Enclave Note: Individuals found on or entering Fort Gordon or Gillem Enclave without proper authonty are sub1ect to remoyal, prosecution or other appropriate action.

By completing blocks 1 through 12, the individual in block 1 (BLK1) authorizes Fort Gordon or Gillem Enclave Law Enforcement Officials to receive a report of the individual's criminal and driver's history record. If requested, the individual agrees to provide a coov of social security card, a coov of driver's license and copies of other identification documents as mav be required.

Individual ln block 1 must put a check mark or X In the box below that designates the purpose for completing this form.

IZJ Access to Fort Gordon or Gillem Enclave □

D Employment with Police/ Security/ Guards

Unit Armorers & D General Employment with Ft Gordon or Gillem Enclave AA&E Key Custodians (Do not check this block 1f vou are a contractor)

D Employment with Children D Employment with Elder Care Type or print neatly in ink, all required information

1 Full Name· (Last First, Middle)

3s \o"} (ls ✓c,� \:> I 4 Current Address· I "' c::. p_ I'\ V-rA /' �

8. Date of Birth: ·(d�mrn/yyyy) 9. Driver's License No.

Jv l J I I .i.,01(:, ;J/A

11. Signature of lndiv al ,1n

2. Home Phone No: 3, Cell or Alternate Phone No:

� {7CJC) 5,SS-12-1: ... ,, __ ,

5. Sex. 6, Race· 7 SSN j<-_s 10 State of Issue.

oaa - oo -ociac:)

Upon signing this form in block 11, I declare that the information provided is complete, true, and correct. I understand that a false statement may subject me to prosecut.ion. (18 USC 1001)

112 Date V'bt.�

Blocks 13 thru 23 are to be completedby a government employee sponsor (GES) / government representhle (GOVREP) or busfness manager (BM). Blocks 13 thru 23 must be completed when requesting access to Fort Gordon or Gillem Enclave for the person listed in BLK 1. A GES or GOVREP must be a Department of Defense (DOD) civilian employee or active duty military.

By completing blocks 13 thru 23, the GES / GOVREP or BM in block 21 verifies the need of individual 13. Company/ Activity/ Club· in BLK1 lo access Fort Gordon or Gillem Enclave lo: perform work, volunteer, be a transportation

{5 r'C Co" rkA.t A- 1 provider provide health cam, v1s1t, or other for (List 1n block 13) Compani, Business, Activity, or MWR

Club Member i.e. Binqo Golf Dinner Theatre Cvclino, Bowhno Horse tables, Soortsman's Club etc.

Individual in BLK1 does not have a current DoD ID card that allows access lo Fort Gordon or Gillem 14 Po�n or l r purpose:

Enclave and requests access in order to better serve as a· (List Position or other purpose in block 14) _C.Jf-.. IU �,.,. -' -

Individual 1n BLK1 has been or will start 15. Date· I, as the GES / GOVREP or BM, anticipate individual 16. Date.

working, volunteenng or other (List date in in BLK1 to be employed. volunteer, or other thru· block 15) (List date in block 16)

The GES / GOVREP or BM will be responsible for notifying the DES representative when \he 1nd1v1dual 17. Activity:

1n BLK1 no longer performs the work, volunteers, 1s a visitor. etc., for: (List company, business. or activity in block 17). i.e. DPW MWR. NEC, COE. DES COMMISSARY, AAFES, EFMP, Health Care Provider, etc.) Directorate or Public Works

(List email of GES / GOVREP or BM tn 18 Email. 19. Phone No 20. Contract No:

block 18, phone No in bloc!< 19 and if chelsea.a.rabun.civ@mail.mil (706) 791-7353 If Known applicable, contract No. in blcick 20) 23 Date. 21 Printed Name of GES I GOVREP or BM· 22. Signature of GES / GOVREP or BM

Chelsea A. Rabun DPW 24 Signature of authorized DES representative: 25 Date· 26 For Official Use Only.

PS Form 190-6, 18 Aprfl 2015

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MUST BE LEGIBLE - PROOF VIEW ALL

COPIES/SCANS - NO Exp. DL's Actual Size - NO enlargements or alterations