Eglin Afb Form 90 PDF Details

Accessing Eglin Air Force Base in Florida requires adherence to specific protocols, as mandated by the Eglin AFB 90 form, an essential document designed to vet individuals prior to granting base entry. This affidavit facilitates a comprehensive background check crucial for determining the suitability of contractors, subcontractors, and their employees for base access, a step integral to maintaining the base's security. The form derives its authority from federal laws and military regulations, including Section 3101 of Title 44, United States Code, and various Air Force instructions and Privacy Act Statements. It details necessary personal information such as social security numbers and dates of birth, used not only to identify individuals but also to aid in the assessment of their access eligibility. Furthermore, the document outlines routine uses of this information, emphasizing that submission is voluntary but necessary for those seeking entry to the base. Its significance extends beyond mere procedure; the form acts as a pledge of accuracy and honesty from the applicant, warning that failure to provide truthful information can lead to severe consequences, including denial of access, fines, or imprisonment. Coupled with a memorandum from the Defense Logistics Agency (DLA) Disposition Services Eglin, which outlines the steps for civilian and commercial carrier access, the Eglin AFB 90 form is a pivotal element of the base's security and operational protocol, ensuring that only properly vetted individuals can conduct business on-site.

QuestionAnswer
Form NameEglin Afb Form 90
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesafb form 90 get, eglin afb form 90, eglin afb form force, fill out eglin online

Form Preview Example

FOR OFFICIAL USE ONLY

EGLIN AIR FORCE BASE ACCESS AFFIDAVIT

 

 

 

 

 

 

 

 

 

 

 

PRIVACY

ACT STATEMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORITY:

 

Section 3101, nUe 44, United States Code, AFI 33-332, 5 USC 552A.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PURPOSE:

 

Used for requesting

 

personal Information to assist

security personnel In developing

records to document contractor

employee suitability for

 

 

 

access to Eglin Air Force Base, Florida to work under Air Force contracts. The SSN and Date of Birth (OOB) are necessary to Identity the

 

 

 

person and records. This Information may be used to determine suitability of persons desiring access to Eglin Air Force Base as well as for

 

 

 

other lawfUl purposes including law enforcement and IltigaUon.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ROUTINE USES:

All contractors,

subcontractors,

unit's or sponsoring activities who have employees not authorized a Command Accese Card or security

 

 

 

 

clearance and requires access to Eglin Air Force Base In performance of their official duties, and/or whose contract expires In less than

 

 

 

 

one year.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISCLOSURE:

 

 

Disclosure

of requested Information

Is voluntary.

Failure

to provide information

could 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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPANY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WORK SITE LOCATION

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF WORK(Emp/oyoo}

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION TO ENTER EGLIN AFB FOR BUSINESS PURPOSES ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DAYS OF WEEK(Check on that

Apply)

 

 

 

 

 

HOURS

 

 

 

 

 

 

 

 

 

 

OWEDNESDAY

 

O THURSDAY

 

 

 

 

 

 

DMONDAY

 

DTUESDAY

 

 

 

 

EARLIEST ENTRY HOUR

 

 

 

 

 

 

 

 

 

 

 

D

FRIDAY

 

OSATURDAY

 

O SUNDAY

 

 

 

LATEST ENTRY HOUR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTRACTOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME (Last, First, Middle (Add

SIIffix Sr., Jr. after

/ast name))

 

 

 

 

 

SSN

 

 

 

 

 

 

 

 

 

 

 

 

HOME PHONE

 

OTHER NAMES ALSO USED (If none, write "NONE")

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

 

 

 

 

 

 

DRIVER LICENSE NUMBER

 

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHPLACE

(CIIy/State/Country)

 

 

 

 

 

 

 

 

 

 

COUNTRY

OF CITIZENSHIP

 

 

 

 

 

 

 

 

RESIDENT ALIEN NUMBER OR IMMIGRATION DOCUMENT NUMBER AND DESCRIPTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

(No P.O. Boxes)

 

 

 

 

 

 

CITY

 

 

STATE

 

ZIP CODE

DMALE

 

 

 

RACE

 

 

 

 

HAIR COLOR

 

EYE COLOR

 

HEIGHT

 

 

WEIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL BODY CHANGES OR TATTOOS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THE INFORMATION ON THIS FORM IS BEING COLLECTED IN ACCORDANCE WITH FEDER LAW PERMITTING THE INSTALlATION COMMANDER TO LIMIT ACCESS TO THE INSTALLATION FOR SECURITY REASONS (50 U.S.C. 797 AND DoD INSTRUCTION 5200.8). THIS DATA WILL BE USED TO SCREEN INDIVIDUALS WHO HAVE OR ARE ARE SEEKING ACCESS TO EGLIN AIR FORCE BASE, flORIDA. FAILURE TO PROVIDE TRUTHFUL, COMPLETE AND ACCURATE RESPONSES MAY BE USED AS A BASIS TO DENY ENTRY TO EGLIN AtA FORCE BASE AND IS ALSO PUNISHABLE AS A CRIMINAL OFFENSE.

EGLIN AFB FORM 90, 201307XX

FOR OFFICIAL USE ONLY

 

 

 

FOR OFFICIAL

USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE ANSINER EACH OF THE FOLLOWING QUESTIONS BY CHECKING THE CORRECT ANSWER. THE INFORMATION YOU PROVIDE WILL 9E VERIFIED

 

THROUGH STATE AND FEDERAL CRIMINAL HISTORY RECORD CHECKS.

 

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YES

 

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CAN U.S. CITIZENSHIP, IMMIGRATION

STATUS, OR SOCIAL

SECURITY

ACCOUNT NUMBER

 

BE VERIFIED?

 

 

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I-IAVE YOU EVER BEEN BARRED FROM ENTRYiACCESS TO ANY FEDERAUMILITARY INSTALLATION OR FACILITY?

ARE YOU WANTED BY FEDERAL OR CIVIL LAW ENFORCEMENT AUTHORITIES, REGARDLESS OF OFFICENIOLA TION

(i.e., an 'order to erresi' has been issued by A judge) ?

HAVE YOU BEEN CONVICTED OF ANY OFFENSE THAT INVOLVED VIOLENCE IN THE WORKPLACE?

HAVE YOU BEEN CONVICTED OF ANY VIOLENT CRIMINAL OFFENSE THAT RESULTED IN DEATH?

HAVE YOU BEEN CONVICTED OF ANY OFFENSE THAT INVOLVED USE OF A WEAPON?

HAVE YOU BEEN INCARCERATED FOR 12 MONTHS OR LONGER. REGARDLESS OF OFFENSENIOLATION, UNLESS RELEASED ON PROOF OF INNOCENCE?

HAVE YOU EVER BEEN CONVICTED OF ESPIONAGE, SABOTAGE, TREASON, OR TERRORISM OR MURDER?

DOES YOU NAME APPEAR ON ANY FEDERAL AGENCY'S'WATCH LIST' OR 'HIT LIST' FOR CRIMINAL BEHAVIOR OR TERRORIST ACTIVITY?

HAVE YOU BEEN PREVIOUSLY DENIED ACCESS TO ANY 000 INSTALLATIONS?

HAVE YOU BEEN CONViCTED OF FIREARMS OR EXPLOSiVES ViOLATION?

HAVE YOU BEEN CONVICTED OF SEXUAL ASSA~LT/ROBBERY, RAPE, CHILD MOLESTATION, DRUG POSSESSION WITH

INTENT TO SELL, DRUG DISTRiBUTION, OR TRAF'FICKING IN HUMANS?

ARE YOU A REGISTERED SEX OFFENDER?

ARE YOU AN UNDOCUMENTED, NON·US., CITIZEN (FOREIGN NATIONAL)?

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NOTE TO APPLICANT: ATTESTATION

I UNDERSTAND THAT BY SIGNING THIS APPUCATION, THE INFORAMTION I H AVE PROVIDED ON THIS APPLICATION IS TRUE, COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF AND IS PROVIDED IN GOOD FAITH .. 1 UNDERSTAND THAT A KNOWING AND WILLFUL FALSE STATEMENT ON THIS APPLICATION CAN 8E PUNISHED BY BARMENT FROM THE INSTALLATION, A FINE, IMPRISONMENT OR BOTH. (18 U.S.C. SECTION 1001).

FURTHER, I UNDERSTAND THAN UNDER THE AUTHORITY OF 50 U.S.C. SECTION 797 AND 0001 5200.8, THE INSTALLATION COMMANDER HAS IMPOSED A CONTINUING OBLIGATION FOR ME TO DISCLOSE TO EGLIN AIR FORCE BASE, WITHIN 24 HOURS, IF I AM CONVICTED OR FOUND NOT GUILTY BY REASON OF INSANITY OF ANY OF THE ABOVE CRIMINAL OFFENSES THAT OCCURS WHILE I HAVE UNESCORTED ACCESS AUTHORITY WITHIN EGLIN AIR FORCE BASE.

APPLICANT NAME (print legibly)

APPLICANT SIGNATURE

COMPANY NAME

COMPANY REPRESENTATIVE NAME

COMPANY REPRESENTATiVE SIGNATURE

EGLIN AFB FORM 90, 201307XX

DATE

FOR OFFICIAL USE ONLY

DEFENSE LOGISTICS AGENCY

DISPOSITION SERVICES EGLIN

210 TRANSPORTATION ROAD, SLOG 525

EGLIN AFS, FL 32542-5212

MEMORANDUM TO DLA DISTRIBUTION SERVICES EGLIN CUSTOMERS

July 15, 2013

FROM: DLA Disposition Services Eglin Security Manager

SUBJECT: Procedures for Access to Eglin Air Force Base, Florida for Civilian Individuals

(NOTE: This includes anyone that does not possess a DoD Identification Card and commercial carriers)

1.Individuals that need access to Eglin Air Force Base, Florida to conduct official business with DLA Disposition Services Eglin will be required to complete a background check, in the form of an affidavit, at least 4 business days prior to the requested date of access, and a memorandum (Visitor Memorandum for Official Business) requesting a visitor pass at least 3 business days prior to the date of the pick-up / drop-off.

2.Those requesting access will send all paperwork to the DAL Disposition Services Eglin Security Manager via regular mail, fax or scan to email. A legible hard copy is needed for submission to the base security office for processing. If using regular mail, please send at least 10 days in advance of access request.

Mail to: DLA Disposition Services Eglin, 210 Transportation Rd., Bldg 525, Eglin AFB, FL 32542

Email to:lyle.weiszhaar@dla.mil

Fax to: (850) 882-3732 or DSN: 872-3732

3.Once the individual has submitted the affidavit and is authorized on base, they will remain in the base system for twelve (12) months. During those 12 months, if the individual needs to return to DLA Disposition Services Eglin, they will only be required to submit the "Visitor Memorandum for Official Business" at least 3 business days in advance of the needed access. Once the 12 month period has expired a new affidavit will need to be re-accomplished.

4.Commercial carriers are requested to have all drivers that may be used for shipments to or from DLA Disposition Service Eglin on Eglin Air Force Base, Florida, complete and submit an affidavit as soon as possible, but at least within the required time frame of 4 business days prior to deliveries. The alternative is that commercial carriers identify a group of personnel for deliveries on to or from DLA Disposition Services Eglin and submit a letter identifying those drivers with their completed affidavits.

2

5.All information contained in the affidavit and request letters will be protected under the Privacy Act of 1974. Any disclosures of this information will follow and are permitted under 5 U.S.c. 552(b) of the Privacy Act, and these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.c. 552a(b)(3). Providing the information requested in the affidavit is completely voluntary however, failure to do so will result in denial of access to Eglin Air Force Base, Florida by the 96 Security Forces and base security function.

6.DLA Disposition Services Eglin is a liaison to the Base Security Forces and does not process the affidavit or badge requests. We are only here to validate the accuracy of the paperwork and submit it to the base Security Forces. We do not have any control of the processing of the paperwork submitted to the base Security Forces and cannot expedite processing. Although we receive notification when the paperwork is completed, we are not informed of why a request is denied.

7.Please address any concerns or questions reqardinqthe submission process to Lye Weiszhaar at (850) 883-4502, or Marie Wilbanks at (850) 883-2224. This process / requirements is effective immediately.

Ld~AAR

secu~a~~ager DLA Disposition S

Attached:

Eglin Air Force Contractor Access Badge Affidavit

Visitor Memorandum Format (for submission each time access is needed)