36C10X18Q9130-004.doc

VA Philadelphia Information Technology Center (PITC) Visitor Access Request

Sponsor completes and submits to “ PITCVisitorAccess@va.gov “ Do not insert sensitive information on this form!

[3] Date/Time Departure:

Visitor Information

(All visitors MUST bring valid driver’s license or other Government-issued photo ID* with them when they visit.)

Visitor’s Full Name

(Must match photo ID) Company (Name, Addr., Phone)

Escorted

Visitor

(no addl information required) Unescorted VA Employee

(no addl information required)

Unescorted Access

Must use an “Unescorted Visitor PII Form

Request PII Form from

“ PITCVisitorAccess@va.gov “ Will be connected to VA network

(Yes/No) Laptop Authorized

(Yes/No)

DO NOT INSERT DOB OR ANY PERSONALLY IDENTIFIABLE INFORMATION ON THIS FORM!

[1] Briefly describe the purpose of the visit.

[4] Enter the name of the person that will be visited.

[2] Enter the date that the visitor(s) will arrive.

[5]Enter the phone number of the person that will be visited.

[3] Enter the date that the visitor(s) will depart.

*Acceptable photo identification cards include state-issued driver’s licenses, state-issued identification cards, U.S. military-issued identification cards, and U.S. passports.

**Non-VA visitors requiring unescorted access are requested to fax the listed information to the Physical Security fax in order to enable a criminal history check to be conducted prior to their visit. Visitors are encouraged to use a fax cover sheet indicating the fax transmission contains sensitive information. Non-VA visitors requiring unescorted access who have not faxed their personally identifiable information prior to the arrival date are encouraged to arrive at least 20 minutes early and are advised that a criminal history check will be conducted while they wait.

***All visitors bringing a laptop that will be connected to the VA network are encouraged to arrive 45 minutes early in order to process the visitor access through physical security and to scan the laptop.