A22_Form_451_Air_Monitoring_Equipment_.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Air Monitoring Equipment Installation
- Solicitation number
- W912ES-17-T-0082
About this file
Form 451
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Amendment_1_Air_Monitoring_Equip.pdf | ||
| WWTP_air_monitoring.pdf | ||
| A22_02_TL_5.3.5_Facility_Standards.docx | DOCX document | |
| A22_Solicitation_Equipment__W912ES-17-T-0082_.pdf |
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Text version
Sheet1
| PRIVACY ACT STATEMENT AUTHORITY: The Privacy Act of 1974, Title 5 USC 552a. PRINCIPLE PURPOSE(S): To determine suitability of individual(s) requesting access to Fort McCoy. This information will be used to generate state and federal criminal history records checks. ROUTINE USE(S): Personal information may be disclosed to appropriate military and civilian emergency and investigation agencies to assist in determining suitability for access to Fort McCoy. DISCLOSURE: Voluntary; however failure to provide information will result in a refusal to grant access to Fort McCoy. | |||
| CONTRACT NUMBER | CONTRACT EXPIRATION DATE | EMPLOYEES POSITION/ EVENT | FULL NAME |
FIRST MIDDLE LAST
| (Middle Name Is Required) | SEX | ||||||||||||||||
| (M/F) | DOB: | DRIVERS LICENSE NUMBER | DRIVERS LICENSE STATE | WILL THE COMPANY OR INDIVIDUAL BE GETTING A RAPIDGate CARD? | RAPIDGATE CARD STATUS: NEW / RENEW / N/A | WILL A PASS BE REQUIRED? | REQUESTED PASS DATES | WORK/ PASS HOURS | WORK AREA/ VISIT LOCATION | OLD/PREVIOUS PASS NUMBER | COMPANY NAME | COR NAME AND PHONE NUMBER | POC NAME AND PHONE NUMBER | ||||
| 10012 | 15-Jan-15 | Example: Plumber / Bagger | Legal Name | ||||||||||||||
| Example: John Edward Doe | M | 29-Apr-64 | F123-4567-8912-54 | WI | Yes / No | New | Yes / No | 25 Jan 15 - | |||||||||
| 30 Jan 15 / N/A | MON-FRI 0700-1700 HOURS | Bldg 100 | 123456 | Commissary / TCI | John Smith,608-388-XXXX | Jane Q. Public, 608-388-0000 | |||||||||||
| N/A | N/A | No | N/A | Yes | 28-Jun-17 | WED 1000 - 1600 | DPW & WWTP | N/A | N/A | Joseph Rath, 608-388-6520 | |||||||
| N/A | N/A | No | N/A | Yes | 28-Jun-17 | WED 1000 - 1600 | DPW & WWTP | N/A | N/A | Joseph Rath, 608-388-6520 | |||||||
| N/A | N/A | No | N/A | Yes | 28-Jun-17 | WED 1000 - 1600 | DPW & WWTP | N/A | N/A | Joseph Rath, 608-388-6520 | |||||||
| N/A | N/A | No | N/A | Yes | 28-Jun-17 | WED 1000 - 1600 | DPW & WWTP | N/A | N/A | Joseph Rath, 608-388-6520 | |||||||
| N/A | N/A | No | N/A | Yes | 28-Jun-17 | WED 1000 - 1600 | DPW & WWTP | N/A | N/A | Joseph Rath, 608-388-6520 | |||||||
| N/A | N/A | No | N/A | Yes | 28-Jun-17 | WED 1000 - 1600 | DPW & WWTP | N/A | N/A | Joseph Rath, 608-388-6520 | |||||||
| FORT MCCOY FORM 451 MAY 2015 v2 | ALL PREVIOUS VERSIONS ARE OBSOLETE | ||||||||||||||||
| NOTE 1: Please enter "N/A" in fields that do not apply. | |||||||||||||||||
| NOTE 2: If the visitor does not have a middle name, enter "NMI" in its place. |
&"-,Bold"FOUO
&"Arial,Bold"&10FORT MCCOY FORM 451 21 May 2015 &"-,Bold"FOUO
Sheet2
| PRIVACY ACT STATEMENT AUTHORITY: The Privacy Act of 1974, Title 5 USC 552a. PRINCIPLE PURPOSE(S): To determine suitability of individual(s) requesting access to Fort McCoy. This information will be used to generate state and federal criminal history records checks. ROUTINE USE(S): Personal information may be disclosed to appropriate military and civilian emergency and investigation agencies to assist in determining suitability for access to Fort McCoy. DISCLOSURE: Voluntary; however failure to provide information will result in a refusal to grant access to Fort McCoy. | ||||||||||||||||||
| CONTRACT NUMBER | CONTRACT EXPIRATION DATE | EMPLOYEES POSITION/ EVENT | FULL NAME | |||||||||||||||
| (FIRST MIDDLE LAST) | SEX | |||||||||||||||||
| (M/F) | DOB: | DRIVERS LICENSE NUMBER | DRIVERS LICENSE STATE | WILL THE COMPANY OR INDIVIDUAL BE GETTING A RAPIDGate CARD? | RAPIDGATE CARD STATUS: NEW / RENEW / N/A | WILL A PASS BE REQUIRED? | REQUESTED PASS DATES | WORK/ PASS HOURS | WORK AREA/ VISIT LOCATION | OLD/PREVIOUS PASS NUMBER | COMPANY NAME | COR NAME AND PHONE NUMBER | POC NAME AND PHONE NUMBER | |||||
| 10012 | 15-Jan-15 | Example: Plumber / Bagger | Legal Name as Appears on Driver's License or State ID. Example: John Edward Doe | M | 29-Apr-64 | F123-4567-8912-54 | WI | Yes / No | New | Yes / No | 25 Jan 15 - 30 Jan 15 / N/A | MON-FRI 0700-1700 HOURS | Bldg 100 | 123456 | Commissary / TCI | John Smith,608-388-XXXX | Jane Q. Public, 608-388-0000 |
| FORT MCCOY FORM 451 MAY 2015 v2 | ALL PREVIOUS VERSIONS ARE OBSOLETE |
| NOTE 1: Please enter "N/A" in fields that do not apply. | |
| NOTE 2: If the visitor does not have a middle name, enter "NMI" in its place. |
&"-,Bold"FOUO
&"Arial,Bold"&10FORT MCCOY FORM 451 21 May 2015 &"-,Bold"FOUO
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