1.06 TE 14 Installation Access Badge Form (NOTU).pdf

"For Official Use Only – Privacy Sensitive – any misuse or unauthorized disclosure may result in civil or criminal penalties.”

VISITOR BADGE REQUEST PERSONAL INFORMATION CCAFS

PERSONAL INFORMATION/MUST BE TYPED (Please read 2nd page)

** PLEASE PROVIDE THE FOLLOWING INFORMATION EXACTLY AS THE EXAMPLE **

NAME OF VISITOR (First, MI, Last)

DATE OF BIRTH (MM/DD/YYYY)

SOCIAL SECURITY NUMBER # (XXX-XX-XXX)

(need full SS# or request cannot be processed)

DRIVER’S LICENSE # & STATE

NAME OF VISITOR’S COMPANY

U.S. CITIZENSHIP (Y or N) No- then need Perm Resident Card # GENDER (M or F)

HEIGHT (ft/in)

WEIGHT (lbs)

EYE COLOR

HAIR COLOR

START DATE (MM/DD/YYYY)

(DETERMINED BY POC & SECURITY)

END DATE (MM/DD/YYYY)

(DETERMINED BY POC & SECURITY)

NAME & PHONE# OF NOTU SPONSOR or POC

DO YOU HAVE A CURRENT GOVT’ CAC

(COMMON ACCESS CARD)

All Visitors to CCAFS must provide the above information and email to or fax to 321-853-7859:

• Mary Scoggins, Personnel Security, 321-853-1290, Mary.Scoggins@ssp.navy.mil (primary to NOTU)

• Paul Carraro, Information Security, 321-853-1174, Paul.Carraro@ssp.navy.mil (alternate)

• Shyrita Pouncey, Security Assistant, 321-853-1173, shyrita.pouncey@ssp.navy.mil (alternate)

• Lance Weiberg, Physical Security, 321-853-4784, Lance.Weiberg@ssp.navy.mil (alternate)

• Horace Jackson – Security Manager, Horace.Jackson@ssp.navy.mil (in emergencies)

• Visitor files in “Section 1” ONLY and verify the information is correct.

• The Sponsor will determine “Start & End” dates/times

• Visit Requests will NOT be kept on standby at Visitor Center for more than 30 days.

"For Official Use Only – Privacy Sensitive – any misuse or unauthorized disclosure may result in civil or criminal penalties.”

VISITOR BADGE REQUEST PERSONAL INFORMATION CCAFS

VISITOR CONTROL CENTER REQUIREMENTS:

• Present two forms of ID which one must be a government approved picture ID.

AND IF DRIVING:

• PERSONAL VEHICLES – The visitor must present their current vehicle registration and proof of insurance at the VCC to drive onto CCAFS. (Required for driver only)

OR

• RENTAL CARS – The visitor must present the car rental agreement and proof of insurance to drive on CCAFS. The VCC will accept Lockheed Martin’s declination of insurance for the rental car. (Required for driver only)

Hours of operation are 0600 to 1600 hours, Mon-Fri except Federal Holidays.

Phone: 321-853-5261

Directions: VCC is 1 block East of: 555 FL-401, Cape Canaveral, FL 32920 (Seaport Canaveral Corp-Large fuel farm)