Access Office Visit Request - FBI CJIS.pdf

Privacy Act Notice

For visitors to the Federal Bureau of Investigation (FBI)

The FBI is authorized to collect the information pursuant to one or more of the following provisions: Title 28, United States Code, section 533; Title 40, United States Code, section 1315(c); Title 28, Code of Federal Regulations, section 102-74, Subpart C, and sections 102-81.5, 102-81.10, and 102-81.15. The information is collected in order to help the FBI determine whether to provide you with access to an FBI facility and to maintain the security of FBI personnel, facilities, and information systems. You do not have to provide the requested information;

however, failure to provide the requested information may result in you being denied access to an FBI facility. The information collected on this form is protected by the Privacy Act of 1974, as amended, Title 5, United States Code, section 552a, and is maintained in one or more of the following systems of records: the FBI’s Security Access Control System, DOJ/FBI-013, notice of which was published in the Federal Register at 70 Fed. Reg. 7516 (Feb. 14, 2005), and the FBI Data Warehouse System, DOJ/FBI-022, notice of which was published in the Federal Register at 77 Fed. Reg. 40631 (July 12, 2012). The information collected may be disclosed in accordance with routine uses contained in those notices or otherwise permitted by law.

May 2016

CJIS Visit Request Form The purpose of this form is to gather information needed to process your visitor for access to FBI facilities.

All information is required to process your visitor for access.

FBI personnel requesting information from individuals in order to complete this form should provide those individuals with a copy of the Privacy Act Notice attached to this form.

Please submit completed form to Access Control Unit BTC1 or fax to (304) 625-3183 or via CJIS UNet – email to CJIS_ACCESS_VISIT_REQUEST

*NOTE: Non-FBI Personnel must submit form to your FBI Point of Contact.

1. Please provide the following FBI POC contact information:

Official Bureau Name:

Extension:

Alternate Number:

2. Please provide the following information for your visitor:

Name (Last, First Middle):

SSN (with dashes):

DOB:

POB (City, State):

U.S. Citizen: Yes No (If No, Skip to section 3)

If Yes: By Birth or Naturalization?

POB Country?

Alien Registration Number?

3. Please provide the Driver’s License Information for your visitor:

Issuing State:

License Number:

4. Please provide the following visit information for your visitor:

Company Name:

Date(s) of Visit:

Performing Contractual Duty: Yes No

5. Please explain the reason for visit:

Access Control Unit Use Only Checks completed: ICE QWI DC/SO Phoenix

Initial/Date:

Form: CJIS/ACU/IF-01 Rev: 10/21/2020