47PD0224R0048 NDWV Courthouse Contractor Form.pdf

UNITED STATES MARSHALS SERVICE

Northern District of West Virginia

Contractor Access Form

After Hours Business Hours Date(s) Time(s)

Sponsoring Agency: Sign/Date:

Agency Primary Contact Name: Primary Contact Phone:

Agency Alternate Contact Name: Alternate Contact Phone:

Agency After Hours Contact Name: After Hours Contact Phone:

Company Name:

Company Point of Contact: Company Phone Number:

HSPD-12/Prox

(Mark if Yes)

Type of work to be performed and in what areas (floor/office number, courtrooms, etc.):

Approved by (USMS):

(This form must be approved by USMS before it can be issued to security)

Please complete this form if your agency requires a contractor to enter the Federal Courthouse to perform an ordered task. Form must be completed, in its entirety, and submitted to USMS for approval, no less than 24 business hours prior to the scheduled ordered task.

When completed, please email this form to: zachary.boyd@usdoj.gov and corey.gonzalez@usdoj.gov, or fax to: (304) 267-9369

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Contractor Access Form

Contractor Information:

Name

(Last, First, MI) DOB Sex/Race

Length Requested

Begin Date

End Date Date of

Background

Contractor’s Vehicle Information:

ONLY if using secured parking lot

Make Model Color License Plate

State Number

Contractor Tool List:

Contractor must provide a complete list of tools and equipment being transported inside the Federal Courthouse (Items can be waved with USMS Approval)

Northern District of West Virginia

REQUEST FOR SECURITY CLEARANCE / PROXIMITY CARD

(Contractors entering the Federal Courthouse without the appropriate clearance level must be escorted by an employee from the sponsoring agency)

NAME:

DATE REQUESTED:

AGENCY/DIVISION:

REASON FOR ISSUE:

NEW – Has undergone a successful Background Investigation

TEMPORARY ISSUE: Start Date: End Date:

INTERN – Intern has undergone a successful Background Clearance

REPLACEMENT:

LOST: FORGOTTEN: DEFECTIVE:

CONTRACTOR HSPD-12/PIV/PIV-I ISSUED: YES: NO:

If NO, please provide:

Escort Employee Name:

Sponsoring Agency Employee Name:

Phone Number:

Northern District of West Virginia

Vehicle Deliveries / Shipments

N/WV: Elkins/Wheeling/Martinsburg

• Full-sized tractor trailers are prohibited from the loading dock. When expecting a delivery, please inform the shipper that the delivery must be made in a standard size “Box Truck” or smaller.

• If a delivery is made with a tractor trailer the contents must be offloaded on the street near loading dock and manually delivered to the loading dock.

N/WV: Clarksburg

• Full-sized tractor trailers are authorized for this loading dock.

Please notify the GSA Building Manager, and CSOs in advance of upcoming scheduled deliveries. Please include date and approximate time of delivery with notice.

* Regular deliveries by USPS, FedEx, UPS, and other similar scheduled delivery companies are excluded. *

FOR USMS USE ONLY

PRINT NAME:

SIGNATURE:

DATE APPROVED:

EXTENSION APPROVED: