Badge_App_04.24.15.pdf

TO BE FILLED OUT BY APPLICANT

1) LAST NAME

FIRST NAME M.I.

YEAR MONTH DAY

DATE OF BIRTH

HAIR COLOR EYE COLOR

FEET INCHES POUNDS

HEIGHT WEIGHT

STATE OF BIRTH

COUNTRY OF BIRTH

( IF OTHER THAN USA)

RACE

HOUSE NUMBER STREET NAME

ADDRESS

CITY STATE POSTAL CODE

PHONE NUMBER

DRIVER LICENSE/ STATE ID NUMBER

Signature of employee Date

3) COMPANY NAME B

Mon Tue Wed Thu Fri Sat Sun

DAYS OF ENTRY

SERVICES PERFORMED

TIMES OF ENTRY

4)

POC NAME/TITLE:

A B C D

FPCON AUTHORIZED

LENGTH AUTHORIZED 1 YEAR 2 YEARS ISSUE DATE:

OTHER EXPIRATION EXPIRATION DATE:

ISSUED BY:

CONTRACTOR BADGE APPLICATION

CAUSCASIAN/WHITE

OTHER (PLEASE SPECIFY)

AFRICAN AMERICAN/BLACK HISPANIC

SOCIAL SECURITY NUMBER

POC SQUADRON/OFFICE: U.S. ARMY CORPS OF ENGINEERS

DATE OF EXPERATION

FORM REVISED 24 APRIL 2015

WARNING: This document contains for official use only(FOUO)and Privacy Act information which must be protected or removed IAW AFI 33-119, AFI 33-219, and DOD

Regulation 5400.7/AF Supplement prior to further disclosure.

FOR OFFICIAL USE ONLY

POC SIGNATURE/DATE:

TO BE FILLED OUT BY POC OR SPONSORING ORGANIZATION

24 Hour Access

2) I authorize the use and release of my personal information to Altus Air Force Base, Oklahoma, to accomplish a national criminal background check to determine access to Altus AFB in connection with proposed business.

SECURITY FORCES USE ONLY

TO BE FILLED IN COMPLETELY BY SPONSORING ORGANIZATION (CHECK ALL THAT APPLY)