08.08_Appendix B_Building Access Request form.pdf

(Rev 2/17)

BUILDING ACCESS REQUEST FORM

***This process does not allow un-escorted access and a Federal Employee must be present while the approved personnel are on site***

[ ] Fingerprints have been submitted electronically – No FP Card Attached (Only applies to PCN Washington DC location) - (To be completed by the ICE Project Manager)

This Section to be completed by the Applicant/Vendor Representative or ICE Project Manager:

Applicant Name: ________________, ____________________, __________

(PRINT) (LAST) (FIRST) (MIDDLE)

SSN – – Date of Birth (MM/DD/YYYY) _____-____-_______

Gender (CIRCLE): M F

Place of Birth (City/State/Country): _______________________________________

Alien or Citizenship # (If applicable): ______________________________________________________

Employment Authorization Card # and Expiration Date (If applicable):

List place(s) (State(s)/Country(ies)) of residence during last three (3) years:

This Section to be completed by an ICE Employee serving as the Project Manager:

Provide Project Description matching information submitted in advance to ICE Industrial Security

Name of contract Vendor: _______________________________________________________________

Project Name/Number/Address: _______________________________________________

Re-check (Circle): YES / NO (If Yes - Date of last check): (MM/DD/YYYY) _____-_____-_________

The below personnel will be notified of vetting action:

ICE Project Manager: e-Mail: _

ICE Field Security Manager: e-Mail: _

ICE Site POC: _________________________________________ e-Mail:________________________

(This Section to be completed by Personnel Security Unit)

Vetting result - (Circle) GRANTED DENIED REJECTED

Adjudicator/Date

APPROVED ACCESS IS ONLY VALID FOR 120 DAYS FROM DATE GRANTED