EAL.pdf

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Repair ACA Briefing Room
Solicitation number
W912SV-16-B-0004
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Entry Authorization Listing (EAL) Worksheet

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104FW Security Forces Squadron

Contractor Entry Authority List

PRIVACY ACT STATEMENT

1. AUTHORITY: Title 50, Appendix, U.S.C., Title 10, U.S.C., Public Law 96-357 96th Congress, September 24, 1980 (Amendment to 10 U.S.C. 2107).

2. PRINCIPAL PURPOSE(S): The information provided on the application will be used to screen individual contractor employees for access to DoD facilities.

3. MANDATORY AND VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL PROVIDING INFORMATION: Disclosure of information requested in this Entry Authorization List (EAL) is voluntary; however, the information must be furnished for the employee to be allowed access to the DoD facility.

Project:

Company/Contractor Name:

Project Manager and Phone:

104FW POC:

104FW POC Phone:

Contractor Employee Information:

Name Driver’s License / State DOB DATE START DATE END kyle.kiepke

FOUO

NameRow1:
DOBRow1:
DATE STARTRow1:
DATE ENDRow1:
NameRow2:
DOBRow2:
DATE STARTRow2:
DATE ENDRow2:
NameRow3:
DOBRow3:
DATE STARTRow3:
DATE ENDRow3:
NameRow4:
DOBRow4:
DATE STARTRow4:
DATE ENDRow4:
NameRow5:
DOBRow5:
DATE STARTRow5:
DATE ENDRow5:
NameRow6:
DOBRow6:
DATE STARTRow6:
DATE ENDRow6:
NameRow7:
DOBRow7:
DATE STARTRow7:
DATE ENDRow7:
NameRow8:
DOBRow8:
DATE STARTRow8:
DATE ENDRow8:
NameRow9:
DOBRow9:
DATE STARTRow9:
DATE ENDRow9:
NameRow10:
DOBRow10:
DATE STARTRow10:
DATE ENDRow10:
NameRow11:
DOBRow11:
DATE STARTRow11:
DATE ENDRow11:
NameRow12:
DOBRow12:
DATE STARTRow12:
DATE ENDRow12:
NameRow13:
DOBRow13:
DATE STARTRow13:
DATE ENDRow13:
NameRow14:
DOBRow14:
DATE STARTRow14:
DATE ENDRow14:
NameRow15:
DOBRow15:
DATE STARTRow15:
DATE ENDRow15:
Text1:
Text2:
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Text5:
Drivers License StateRow1:
Drivers License StateRow2:
Drivers License StateRow3:
Drivers License StateRow4:
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Drivers License StateRow12:
Drivers License StateRow13:
Drivers License StateRow14:
Drivers License StateRow15:
Drivers License Row1:
Drivers License Row2:
Drivers License Row3:
Drivers License Row4:
Drivers License Row5:
Drivers License Row6:
Drivers License Row7:
Drivers License Row8:
Drivers License Row9:
Drivers License Row10:
Drivers License Row11:
Drivers License Row12:
Drivers License Row13:
Drivers License Row14:
Drivers License Row15:

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