DESForm190-2-GroupApplication2.pdf

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Attached to
DPM Transportation Services
Solicitation number
W91QF5-25-R-0004
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This is a DES Form 190-2, a Request for Background Check and Access Credential form used for group, family, graduation, and special event access requests at Fort Gregg-Adams Installation. The form is specifically designed for submitting background checks and issuing long-term access credentials for groups of employees working under a single contract, or for group requests like family visits and special events.

The form requires detailed personal information including name, SSN, date of birth, and driver's license information, and must be submitted by a Contracting Officer's Representative (COR) or Government Employee Sponsor (GES). Access credentials are issued for a maximum of 1 year or until contract expiration, ID expiration, or visit duration ends, whichever comes first. The form can be submitted either digitally with encryption from a .mil email account or hand-delivered in person. The document emphasizes privacy protection and includes specific handling instructions as it contains Privacy Act information, requiring direct delivery to intended recipients and preventing person-to-person passing of the form.

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Request for Background Check and Access Credential

(Utilize for Group/Family/Graduation and Special Event access requests)

Company / Event: Sponsor / COR Name: Phone:

Gov. Organization: Contract Number: Start Date: End Date:

Last Name First Name MI Sex Date of Birth SSN DL / ID # State Expiration

Visitor Control Center Use Status Print Name

1. I certify that all information contained on this application has been verified.

2. All individuals contained on this application do not require a DoD Common Access Card (CAC). Sponsor / COR Signature:

DES FORM 190-2, APR 2023 (PREVIOUS EDITION IS OBSOLETE) Page 1 of 2

DES FORM 190-2, Group Application Instruction

DES Form 190-2 is utilized to apply for background checks and issuance of long term access credentials for a group of employees, working for a single company under a single contract. This form may also be used for group requests such as family visits, graduations and special event access requests.

For short term individual submissions use DES Form 190-3

This form is to be used by the COR (Contracting Officer's Representative) or GES (Government Employee Sponsor) for requests performing official business to organizations / tenant activities on Fort Gregg-Adams and for the Sponsor for group family visit, graduation and special event access requests.

DO NOT HAVE THIS FORM PASSED FROM PERSON TO PERSON

This form contains privacy act information, and must be protected.

The COR / GES / Sponsor must collect this information and fill in the form.

The COR / GES / Sponsor must ensure individuals providing the information are aware of the privacy act statement

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY: Title 5, USC 3331, 552, 552a; 10 USC 10204; Executive Orders (EO) 10450, 10865, and 12333.

PRINCIPAL PURPOSE: The information requested is for the purpose of granting access to the Fort Grgg-Adams Installation.

ROUTINE USES: Basis for determinatio n of qualifications and background information for eligibility for access to Fort Gregg-Adams Installation. The Social Security Number (SSN), required for record accuracy, is requested pursuant to EO 9397.

DISCLOSUR E: Providing requested information, to include your SSN is voluntary. However, your access may not be granted if all requested information is not provided.

Contents shall not be disclosed, discussed, or shared with individuals unless they have a direct need-to-know in performance of their official duties. Deliver this document directly to the intended recipient. DO NOT drop off or send to a third-party. This document contains personal or privileged information and should be treated as "For Official Use Only (FOUO)".

It is the COR / GES responsibility to ensure proper notification is given when any person or company is no longer serving in the capacity indicated in the request.

NOTE: Access credentials will be issued for a period not exceeding the lessor of:

a) 1 year

b) Expiration of contract

c) Expiration date of the ID of the individual.

d) Duration of visit (family, graduation and/or special event)

Submission:

The DES Form 190-2 can be submitted through the following two (2) methods:

1. The COR / GES / Sponsor can digitally sign the form and send request encrypted from their “.mil” email account.

a. Mail to: usarmy.gregg-adams.imcom.list.des-access-control-forms-submissions@army.mil

2. Sign the form and personally hand deliver it.

DES FORM 190-2, APR 2023 (PREVIOUS EDITION IS OBSOLETE) Page 2 of 2 mailto:usarmy.lee.imcom.list.des-access-control-forms-submissions@mail.mil

Company Event:
Sponsor COR Name:
Phone:
Start Date:
End Date:
Last NameRow1:
First NameRow1:
MIRow1:
SexRow1:
Date of BirthRow1:
SSNRow1:
DL ID Row1:
StateRow1:
ExpirationRow1:
StatusRow1:
Print NameRow1:
Last NameRow2:
First NameRow2:
MIRow2:
SexRow2:
Date of BirthRow2:
SSNRow2:
DL ID Row2:
StateRow2:
ExpirationRow2:
StatusRow2:
Print NameRow2:
Last NameRow3:
First NameRow3:
MIRow3:
SexRow3:
Date of BirthRow3:
SSNRow3:
DL ID Row3:
StateRow3:
ExpirationRow3:
StatusRow3:
Print NameRow3:
Last NameRow4:
First NameRow4:
MIRow4:
SexRow4:
Date of BirthRow4:
SSNRow4:
DL ID Row4:
StateRow4:
ExpirationRow4:
StatusRow4:
Print NameRow4:
Last NameRow5:
First NameRow5:
MIRow5:
SexRow5:
Date of BirthRow5:
SSNRow5:
DL ID Row5:
StateRow5:
ExpirationRow5:
StatusRow5:
Print NameRow5:
Last NameRow6:
First NameRow6:
MIRow6:
SexRow6:
Date of BirthRow6:
SSNRow6:
DL ID Row6:
StateRow6:
ExpirationRow6:
StatusRow6:
Print NameRow6:
Last NameRow7:
First NameRow7:
MIRow7:
SexRow7:
Date of BirthRow7:
SSNRow7:
DL ID Row7:
StateRow7:
ExpirationRow7:
StatusRow7:
Print NameRow7:
Last NameRow8:
First NameRow8:
MIRow8:
SexRow8:
Date of BirthRow8:
SSNRow8:
DL ID Row8:
StateRow8:
ExpirationRow8:
StatusRow8:
Print NameRow8:
Last NameRow9:
First NameRow9:
MIRow9:
SexRow9:
Date of BirthRow9:
SSNRow9:
DL ID Row9:
StateRow9:
ExpirationRow9:
StatusRow9:
Print NameRow9:
Last NameRow10:
First NameRow10:
MIRow10:
SexRow10:
Date of BirthRow10:
SSNRow10:
DL ID Row10:
StateRow10:
ExpirationRow10:
StatusRow10:
Print NameRow10:
Last NameRow11:
First NameRow11:
MIRow11:
SexRow11:
Date of BirthRow11:
SSNRow11:
DL ID Row11:
StateRow11:
ExpirationRow11:
StatusRow11:
Print NameRow11:
Last NameRow12:
First NameRow12:
MIRow12:
SexRow12:
Date of BirthRow12:
SSNRow12:
DL ID Row12:
StateRow12:
ExpirationRow12:
StatusRow12:
Print NameRow12:
Last NameRow13:
First NameRow13:
MIRow13:
SexRow13:
Date of BirthRow13:
SSNRow13:
DL ID Row13:
StateRow13:
ExpirationRow13:
StatusRow13:
Print NameRow13:
Last NameRow14:
First NameRow14:
MIRow14:
SexRow14:
Date of BirthRow14:
SSNRow14:
DL ID Row14:
StateRow14:
ExpirationRow14:
StatusRow14:
Print NameRow14:
Last NameRow15:
First NameRow15:
MIRow15:
SexRow15:
Date of BirthRow15:
SSNRow15:
DL ID Row15:
StateRow15:
ExpirationRow15:
StatusRow15:
Print NameRow15:
Last NameRow16:
First NameRow16:
MIRow16:
SexRow16:
Date of BirthRow16:
SSNRow16:
DL ID Row16:
StateRow16:
ExpirationRow16:
StatusRow16:
Print NameRow16:
Last NameRow17:
First NameRow17:
MIRow17:
SexRow17:
Date of BirthRow17:
SSNRow17:
DL ID Row17:
StateRow17:
ExpirationRow17:
StatusRow17:
Print NameRow17:
Last NameRow18:
First NameRow18:
MIRow18:
SexRow18:
Date of BirthRow18:
SSNRow18:
DL ID Row18:
StateRow18:
ExpirationRow18:
StatusRow18:
Print NameRow18:
Last NameRow19:
First NameRow19:
MIRow19:
SexRow19:
Date of BirthRow19:
SSNRow19:
DL ID Row19:
StateRow19:
ExpirationRow19:
StatusRow19:
Print NameRow19:
Last NameRow20:
First NameRow20:
MIRow20:
SexRow20:
Date of BirthRow20:
SSNRow20:
DL ID Row20:
StateRow20:
ExpirationRow20:
StatusRow20:
Print NameRow20:
Last NameRow21:
First NameRow21:
MIRow21:
SexRow21:
Date of BirthRow21:
SSNRow21:
DL ID Row21:
StateRow21:
ExpirationRow21:
StatusRow21:
Print NameRow21:
Last NameRow22:
First NameRow22:
MIRow22:
SexRow22:
Date of BirthRow22:
SSNRow22:
DL ID Row22:
StateRow22:
ExpirationRow22:
StatusRow22:
Print NameRow22:
Last NameRow23:
First NameRow23:
MIRow23:
SexRow23:
Date of BirthRow23:
SSNRow23:
DL ID Row23:
StateRow23:
ExpirationRow23:
StatusRow23:
Print NameRow23:
Last NameRow24:
First NameRow24:
MIRow24:
SexRow24:
Date of BirthRow24:
SSNRow24:
DL ID Row24:
StateRow24:
ExpirationRow24:
StatusRow24:
Print NameRow24:
Last NameRow25:
First NameRow25:
MIRow25:
SexRow25:
Date of BirthRow25:
SSNRow25:
DL ID Row25:
StateRow25:
ExpirationRow25:
StatusRow25:
Print NameRow25:
Organization:
Contract Number:

File details come from the government source that posted it. Updated .