Form Exchange Form 3900 Exchange Form 3900 Background Check for Vendors/Contractors

OMB NO. 0702-0135
OMB approval expires
MMM DD, YYYY

Background Check for Vendors/Contractors

AF

PRIVACY ACT STATEMENT

T

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0135, is estimated to average 30 minutes
per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington
Headquarters Services, at [email protected]. Respondents
should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty
for failing to comply with a collection of information if it does not display a currently valid OMB control
number.

AUTHORITY: 10 U.S.C. §7103, “Secretary of the Army”; 10 U.S.C. §9013, “Secretary of the Air Force”;
United States Presidential Executive Order (E.O.) 13526, “Classified National Security”; E.O. 10450,
“Security Requirements for Government Employment”; Department of Defense Instruction (DoDI)
5200.01, “DoD Information Security Program and Protection of Sensitive Compartmental Information”;
DoDI 5200.02, “DoD Personnel Security Program (PSP)”; Army Regulation (AR) 380-67, “Personnel
Security Program”; Air Force Instruction (AFI) 31-501, “Personnel Security Program Management”; AFI
31-401, “Information Security Program Management”; AR 215-8/AFI 34-211(I), “Army and Air Force
Exchange Service Operations”; and E.O. 9397, (SSN), as amended.

R

PRINCIPAL PURPOSES: To assist in the processing of personnel security clearance actions; to record
security clearances issued or denied, and to verify for access to classified information or assignment to a
sensitive position.

D

ROUTINE USES: Records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3)
regarding DoD “Blanket Routine Uses” published at
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. Information may be released
to Federal agencies based on formal accreditation as specified in official directives; regulations; to
Federal, State, Local, and Foreign Law Enforcement, Intelligence, or Security agencies in connection with a
lawful investigation under their jurisdiction.

DISCLOSURE: Voluntary, however, failure to provide information may result in denial of a Common
Access Card; non-enrollment in the Defense Enrollment Eligibility Reporting System
(DEERS); refusal to grant access to DoD installations, buildings, facilities, computer systems and networks;
and denial of DoD benefits if otherwise authorized.
A copy of the Privacy Impact Assessment (PIA) for the collection of information may be located at https://www.aafes.com/aboutexchange/public-affairs/FOIA/assessments.htm

SYSTEM OF RECORD NOTICE (SORN): 1703.03, "Personnel Security Clearance Case Files"; https://dpcld.defense.gov/Privacy/
SORNsIndex/DOD-Component-Notices/Army-Article-List/
EXCHANGE FORM 3900-006

Request for Facility Access Instructions
(Background Check for Vendors/Contractors)
Form 3900-006
Before continuing, please read the Consent to Criminal History Disclosure Notice and the Privacy
Act Statement at the top of page one.

2.

Sections I – V must be completed when unescorted facility access is being requested for a
contracted associate. Any questions relative to what to provide in each section of this form or
what attachments should be included when submitting the completed form should be directed
to your Exchange Person of Contact (POC) or Resource Administrator (RA).

3.

Information you provide will be used by an approved Exchange associate for screening purposes
for you to gain unescorted facility access at Exchange facilities.

4.

Your RA must complete Section 1 by selecting the appropriate request type for system and
badge access.

5.

You must provide your personal information in Section II.

6.

You must provide your citizenship information in Section III. All non-U.S. citizens must provide
an Alien registration number or Employment of Authorization Document (EAD). The original
document must be presented at time of fingerprints appointment, (if onsite at Exchange HQ) or
prior to actual onboarding scheduled date. This information will be verified by an approved
Exchange associate.

7.

You must provide your vehicle information if you will be parking on the Exchanged leased
property or assigned parking lots in Section IV.

8.

Your Exchange POC or RA must provide your reason for access to the Exchange facility in
Section V.

9.

You must read the agreement statement; then sign and date in the space provided in Section V.

10.

Using the delivery methods provided to you, submit this form to your Exchange POC or RA.

11.

Your Exchange POC or RA will provide all other information and submit to the appropriate
personnel for facility access approval/denial.

D

R

AF

T

1.

12.

Your Exchange POC or RA will notify you of the final decision.

EXCHANGE FORM 3900-006

OMB NO. 0702-0135
OMB approval expires
JUN 30, 2019

Army & Air Force Exchange Service (The Exchange)

Background Check for Vendors/Contractors
REQUEST FOR FACILITY ACCESS

Consent to Criminal History
I hereby acknowledge that with the voluntary completion of this form, I am requesting access to a
Department of Defense (DoD) facility in accordance with HSPD-12 credentialing and the Exchange
EOP 66.04. I understand that assignments exceeding 6 (six) months require re-verification by Force
Protection and every 6 (six) months thereafter until my service is no longer required.
I. REQUEST TYPE (Select all that apply)
System Access Required

Initial

Sensitive/Remote

Renewal

Non-Sensitive

Badge Expiration Date (dd/mmm/yyyy)
Not Applicable

T

Badge Request

II. PERSONAL INFORMATION (Print clearly for timely processing)
Name (Last):

First:

Social Security #:

Driver License State #:

Address (Home):

Color Hair:

Place of Birth (City):

Gender:

Driver License State of Issue:

Phone/Area Code:

Country of Birth:

Place of Birth (State):

AF

Date of Birth: (dd/mmm/yyyy)

Middle:

Height:

Color Eyes:

Yes

Have you ever been convicted of a felony?

No

Weight:

Country of Citizenship:

If Yes. How many years since conviction?

(Years)

III. CITIZENSHIP

Non-U.S. Citizens must provide an Alien Registration Number or Employment Authorization Document (EAD) Number and original cards with the
request. Access to the facility will not be authorized without this information. I attest, under penalty or perjury, that I am (select one):
Citizen of the United States

Non-U.S. Citizen, indicate # of consecutive years lived in the U.S.:

Lawful Permanent Resident

Alien Registration Number:

Alien with Employment Authorization
Document #
Document (EAD)

Date Entered the United States: (dd/mmm/yyyy)

(Years)

IV. VEHICLE INFORMATION

License Plate #:

Veh. Color:

Veh. Model:

R

Veh. Make:
Contact Phone # at work:

Cell #:

State of Issuance:

Email Address:

V. REASON FOR ACCESS

(Select one):

Delivery

Vendor

Contractor

Company/Contractor Phone #:

Company/Contractor Name:

Other

(Explain)

Assignment/Area of Worksite of Activity:

(Indicate Floors Required for Access)

D

Indicate Business Justification for Access:
Contract #:

Contract Expiration Date: (dd/mmm/yyyy)

Indicate Number of Hours:

(Select one):

How long will you need access?
Point of Contact (POC) Name:

Facility #:

1-3 Months

3-6 Months

6-12 Months

POC's Command:

POC's Phone #:

Less than 40 hours
Onboarding:

40 hours
Start Date:

End Date:

(dd/mmm/yyyy)

I agree to return the assigned badge to the Security Office upon completion of my assignment, termination of employment or any reason that may cancel or
alter my privilege to enter this facility. By signing this document, I certify that the above information is true and agree to adhere to the rules and regulations of
this facility. I understand that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the
completion of this form.
Date: (dd/mmm/yyyy)
Signature:

APPLICATION PROCESSING (FP Only)
Approved

Date Received: (dd/mmm/yyyy)

Not Approved

Fingerprints Verification Date: (dd/mmm/yyyy)

Date Processed: (dd/mmm/yyyy)
Force Protection Certifying Official:
EXCHANGE FORM 3900-006 (REV JAN 19)

Fingerprint Results:
No Record
Record