CONTRACTOR_AFFIDAVIT_FORM_CRTC_01_Jan_2011.pdf

CONTRACTOR/SUBCONTRACTOR ACCESS AFFIDAVIT

(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)

CONTRACT NUMBER & PERIOD OF PERFORMANCE

Submit original to MSCRTC/SFS. This data will be used to screen individuals who have or are seeking access to Gulfport, MSCRTC or facilities controlled by Gulfport, MSCRTC. Please answer each question. Access will be denied if this questionnaire is incomplete or missing from the Contractor Access Package. This information will be used to generate state and federal criminal history records checks.

Section I. P E R S O N A L I N F O R M A T I O N

1. NAME (Last, First, Middle) 2. ALIASES (AKA) 3. SSN 4. DATE OF BIRTH (YYYYMMDD)

5. EMPLOYER AND ADDRESS (Include City/State/ZIP Code) 6. CURRENT RESIDENCE ADDRESS (Include City/State/ZIP Code)

LOCAL PHONE #

7. SEX 8. RACE 9. EYE COLOR 10. HAIR COLOR 11. HEIGHT 12. WEIGHT

Section II. P L A C E O F B I R T H

1. CITY 2. STATE (If applicable) 3. COUNTRY

4. CITIZENSHIP 5. RESIDENT ALIEN # OR IMMIGRATION DOCUMENT # AND DESCRIPTION

Section III. P L E A S E A N S W E R T H E F O L L O W I N G Q U E S T I O N S YES NO

1.) Have you ever been barred from entry/access to any military installation or facility?

2.) Are you wanted by federal or civilian law enforcement authorities, regardless of offense or violation (i.e., has a judge issued an order for your arrest)?

3.) Have you ever been incarcerated regardless of offense or violation?

4.) Have you ever been convicted of a firearms or explosive violation within the past seven years?

5.) Have you ever been convicted of espionage, sabotage, treason or terrorism, murder, sexual assault, armed assault or robbery, rape, child molestation, felony drug possession with intent to sell or drug distribution?

IF YOU ANSWERED YES TO ANY OF THE ABOVE, PLEASE PROVIDE A FULL EXPLANATION.

Section IV. NOTE TO APPLICANT: ATTESTATION

I attest to the fact that I have been briefed by my employer and understand the purpose for the contractor background check. I understand the information on this form is being collected in accordance with 50 U.S.C., Section 797, and DoDD 5200.8 federal laws permitting the installation commander to limit access to the installation for security reasons and that this data will be used to screen DoD contractor employees who have or are seeking access to US Air Force installations. I have voluntarily completed this “Form” and shall provide the Air Force a specimen of my fingerprints, if/when requested. I understand that by signing this application, I acknowledge that I have been made aware of and have reviewed the list of Gulfport CRTC “Disqualifying Factors” above. I hereby give my consent and authorization for the Air Force to conduct any additional background screenings deemed necessary over the next 24 months, unless otherwise directed by MSCRTC Contracting Squadron, to include comparing/checking my fingerprints against local, state, and federal criminal databases.

The information I have provided on this application is true, complete, and correct to the best of my knowledge and belief, and is provided in good faith. I understand that a knowing and willfully false statement on this application can be punished by fine or imprisonment or both (18 U.S.C section 1001).

Applicant Signature: ______________________________________ Date:_______________

Company Name: ______________________________________________

MSCRTC/Contractor/Subcontractor Access Affidavit Form (1 Jan 2011) Page 1of 2

Section V. P R I V A C Y A C T S T A T E M E N T

Authority: 50USC Section 797; E.O.9397

PRINCIPAL PURPOSE(S): The purpose for requesting personal information is to assist Security Forces personnel in documenting contractor employee suitability for access to USAF installations. The Social Security Number (SSN) and Date of Birth (DOB) are necessary to identify the person and records. This information may be used to determine suitability of person desiring access to Gulfport, MSCRTC; as well as, for lawful purposes including law enforcement and litigation. This information will be used to generate state and federal criminal history records checks.

INTENDED USE: For all contractors and subcontractors who are not authorized a Common Access Card (CAC) and require regular and frequent access to the installation in performance of their official duties.

DISCLOSURE: Disclosure of requested information is voluntary; however, failure to provided information will result in access privileges being refused or withdrawn. The Privacy Act Statement will apply throughout the duration of the Air Force contract while serving in the capacity of prime contractor or subcontractor/supplier employee.

Section VI. A G E N C Y D I S C L O S U R E

The public reporting burden for this collection of information is estimated to take three to 30 days per response, including the timeframe for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information.

Section VII. SPONSORING ORGANIZATION OR COMPANY REPRESENTATIVE SECTION ONLY

Signature/Print name of Company Representative Title Date Phone

Section VIII. DoD SPONSORING ORGANIZATION INFORMATION 1.) Enter name and office symbol of DoD/GOVERNMENT SPONSORING agency:

2.) Enter DoD GOVERNMENT SPONSORING agency’s point of contact full name/Title or Rank:

3.) Enter DoD GOVERNMENT SPONSORING agency’s point of contact phone number:

4.) DoD GOVERNMENT SPONSORING POC printed name, signature, and date:

Signature Print name Date

MSCRTC/Contractor/Subcontractor Access Affidavit Form (01 Jan 2011) Page 2 of 2

Signature/Print name of Company Representative Title Date Phone

Gulfport MS 39503