Eglin Afb is home to one of the most versatile and effective air forces in the world. With its wide range of capabilities, Eglin is able to fulfill any mission requirement asked of it. From conventional warfare tospecialized operations, Eglin is ready for anything. Recently, Eglin completed a new Form 90 submission, detailing all its capabilities and ensuring that it remains one of the most effective fighting forces in the world. This form is an important document, outlining everything from Eglin's personnel to its aircraft and weapons systems. The completion of this form ensures that Eglin will continue to be a vitally important part of America's defense system. Thanks for reading!
| Question | Answer |
|---|---|
| Form Name | Eglin Afb Form 90 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | afb form 90 get, eglin afb form 90, eglin afb form force, fill out eglin online |
FOR OFFICIAL USE ONLY
EGLIN AIR FORCE BASE ACCESS AFFIDAVIT
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PRIVACY |
ACT STATEMENT |
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AUTHORITY: |
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Section 3101, nUe 44, United States Code, AFI |
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PURPOSE: |
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Used for requesting |
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personal Information to assist |
security personnel In developing |
records to document contractor |
employee suitability for |
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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 |
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person and records. This Information may be used to determine suitability of persons desiring access to Eglin Air Force Base as well as for |
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other lawfUl purposes including law enforcement and IltigaUon. |
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ROUTINE USES: |
All contractors, |
subcontractors, |
unit's or sponsoring activities who have employees not authorized a Command Accese Card or security |
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clearance and requires access to Eglin Air Force Base In performance of their official duties, and/or whose contract expires In less than |
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one year. |
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DISCLOSURE: |
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Disclosure |
of requested Information |
Is voluntary. |
Failure |
to provide information |
could result In access privileges |
being refused or |
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withdrawn. The Privacy Act Statement will apply throughout the duration of the Air Force contract while serving In the capacity of prime |
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contractor |
or subcontractor/supplier |
employee. |
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COMPANY |
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NAME |
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PHONE |
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WORK SITE LOCATION |
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TYPE OF WORK(Emp/oyoo} |
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AUTHORIZATION TO ENTER EGLIN AFB FOR BUSINESS PURPOSES ONLY |
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DAYS OF WEEK(Check on that |
Apply) |
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HOURS |
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OWEDNESDAY |
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O THURSDAY |
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DMONDAY |
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DTUESDAY |
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EARLIEST ENTRY HOUR |
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FRIDAY |
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OSATURDAY |
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O SUNDAY |
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LATEST ENTRY HOUR |
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CONTRACTOR |
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NAME (Last, First, Middle (Add |
SIIffix Sr., Jr. after |
/ast name)) |
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SSN |
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HOME PHONE |
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OTHER NAMES ALSO USED (If none, write "NONE") |
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DATE OF BIRTH |
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DRIVER LICENSE NUMBER |
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STATE |
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/ |
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BIRTHPLACE |
(CIIy/State/Country) |
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COUNTRY |
OF CITIZENSHIP |
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RESIDENT ALIEN NUMBER OR IMMIGRATION DOCUMENT NUMBER AND DESCRIPTION |
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STREET ADDRESS |
(No P.O. Boxes) |
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CITY |
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STATE |
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DMALE |
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RACE |
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HAIR COLOR |
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EYE COLOR |
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HEIGHT |
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WEIGHT |
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D |
FEMALE |
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PHYSICAL BODY CHANGES OR TATTOOS |
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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
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FOR OFFICIAL |
USE ONLY |
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PLEASE ANSINER EACH OF THE FOLLOWING QUESTIONS BY CHECKING THE CORRECT ANSWER. THE INFORMATION YOU PROVIDE WILL 9E VERIFIED |
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THROUGH STATE AND FEDERAL CRIMINAL HISTORY RECORD CHECKS. |
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,.... |
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YES |
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NO |
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_ .. |
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3 |
.~ ~ .~ |
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~"" |
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n |
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L.J |
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CAN U.S. CITIZENSHIP, IMMIGRATION |
STATUS, OR SOCIAL |
SECURITY |
ACCOUNT NUMBER |
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BE VERIFIED? |
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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
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
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)
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
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.
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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)
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)