Contractor Access form

CUI
Contractor Access Request Form

Pre-Bid

Awarded

179th Security Forces Squadron
Installation Access Section

*MUST BE DELIVERED A MINIMUM OF FIVE (5) DUTY DAYS PRIOR TO PROJECT START DATE*

Project Number
Last Name
DL State-Number

PBXP 272018 &272019

Project Location B422 Breakroom; B300 BDOC
Start Date 11/17/2026
End Date
First Name
DOB
Social Security #
Email Address
Phone Number

11/17/2026

DECLARATION OF RESPONSIBILITY: By signing below, I agree to take full responsibility for those individual(s) that I have requested unescorted entry for. I have advised the individuals listed below that the possession of illegal drugs or substances will result in prosecution by local authorities, and that no weapons are allowed onto the installation by any contractor. Weapons restrictions apply to CCW holders as well as State certified police officers unless on official duty. Violations of these prohibitions as well as base policies and procedures could result in the individual’s base access being revoked. I have advised the individuals listed below that their vehicles to include equipment, toolboxes, and personal bags such as duffel bags, backpacks, lunch boxes, etc. are subject to search upon entering and exiting the installation. If any of the individuals listed below no longer require access prior to expiration I will notify the 179 SFS Installation Access Section. If new workers are hired, I will submit another Contractor Access Request Form no later than five (5) days prior to their start date. I understand that neither I nor any other member of my staff may escort any individual onto the installation. Individuals requiring escorts must be escorted by a military member assigned to oversee the project. I understand decisions made by the 179 SFS to deny access to any individuals listed below are final and not subject to appeal and that Security Forces will not provide specific causes for denial.

SIGNATURE:

Contractor Information

(All information below is required. Omitting any information will result in the individual being denied access) Last Name

First Name

MI

Date of Birth

U.S. Citizen
(Y/N)

Social Security No./
Passport/Visa No.

** For Pass & ID Use Only**
Driver’s License
State-Number

REAL ID

(Y/N)

VALID

(Y/N)

Denial Reason

PRIVACY ACT STATEMENT

PRIVACY ACT 1974: Contents shall not be disclosed, discussed, or shared with individuals unless they have direct need-to-know in the performance of their official duties. Deliver this document directly to the intended recipient. DO NOT drop off with a third-party.