SAMPLE_VAR_2017.docx
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- Solicitation number
- 47PM0217R0016
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Example of VAR form for Site Visit
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*SAMPLE*
VISITOR AUTHORIZATION REQUEST
Company’s Name Company’s Physical Address Phone: #, Fax: # (Must be on company letterhead) April 05, 2017 ATTN: Ms. Kimberly Baugher Department of State
DS/IS/IND
SA-20 13th Floor 1801 North Lynn Street Rosslyn, VA 22209 Fax (571) 345-3000 or e-mail: DS_IND_contractorVARS@state.gov
This is to advise the Department of State of the clearance level(s) of the following U.S. citizen who will be performing on contract #: _____________; Task Order #:_________________Subcontract #:_________________.
Name/Title/SSN# DOB/POB Clearance/Date/Issuing Agency
| Name | Date of Birth | Clearance Level (TS/S/Interim S) | ||
| Job Title | Place of Birth | Date of Issuance | ||
| SSN # | Citizenship | Defense Security Service |
| Name | Date of Birth | Clearance Level (TS/S/Interim S) | ||
| Job Title | Place of Birth | Date of Issuance | ||
| SSN # | Citizenship | Defense Security Service |
(MORE THAN ONE PERSON’S INFORMATION CAN BE INCLUDED ON A VAR)
GSA or DOS Contracting Officer: John Doe, (202) 205-8468
DOS Point of Contact/ (COR): Jane Doe, (202) 647-9235
Purpose of Visit: Contract performance supporting construction effort (etc.)
Visit Location: Dept. of State – 2201 C St, NW Washington, D.C. 20520
Dates of Visit: (05/05/2017– 05/04//2018) One year from the date of the VAR
Onsite Person to Visit: Jane Doe, (202) 647-9235
Facility Clearance: TOP SECRET; CAGE Code: ##### DSS Your DSS Cognizant Security Office Address:
Sincerely, (Signature) Print Name Facility Security Officer
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