SFFL_4_Short_Term_EAL_Form_2017_(003).pdf

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Repair HVAC System Bldg. 1907 JBMDL
Solicitation number
W912BU-18-B-0011
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List that needs to be completed and returned to Mr. John Mychalczuk by 3:00 P.M. on 27 July, 2018

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SFFL 4

PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. 301.10 U.S.C. 8012 and 8034, and EO 9397.

PRINCIPAL PURPOSE: To verify individual status and conduct any background checks to determine if access to Joint Base McGuire-Dix-Lakehurst(JB

MDL) is warranted. ROUTINE USE: All information will be maintained in a central Security Forces database and may be disclosed to public affairs and security representatives to carry out official duties. Information will not be considered “Public Domain” and will be safeguarded by the end users.

DISCLOSURE: Information collected on this form and your signature are voluntary. If you have no objection to these procedures fill out the form and sign your name. Failure to provide the requested information or a signature may lead to denial of access and privileges at JB MDL.

MEMORANDUM FOR 87 SFS/ Police Services

FROM:

SUBJECT: Short Term Entry Authority List (EAL)

1. Request entry for the following individual be allowed acces onto Joint Base MDL for the purpose of XXXXX at the .

2. I work in building and can be reached at

3. The visitor will be going to ___________

4. Dates Access required: Start Date End Date: .

NAME

(Last, First Middle Intial)

COMPANY

NAME

FULL SSAN Date of Birth Days of week access required

Hours of day access required

3. Please direct any questions regarding this matter to me.

Signature

FIRST MI LAST, RANK, SERV

Title, Organization

1402628380A Typewritten Text

1402628380A Typewritten Text

1402628380A Typewritten Text

1402628380A Typewritten Text

1402628380A Typewritten Text

1402628380A Typewritten Text Sponsor's Last 4:

Building: 5317
Location: Bldg. 1907
Start Date: 8/3/18
End Date: 8/3/18
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Sponsor name:
Purpose: Repair HVAC Bldg. 1907 Site Visit
Organization:
From:
Phone #: 609-562-4057

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