SAMPLE_VAR_2017_HST_3234.docx
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- Solicitation number
- 47PM0217R0016
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*SAMPLE*
VISITOR AUTHORIZATION REQUEST
Company’s Name Company’s Physical Address Phone: #, Fax: # (Must be on company letterhead) October 31, 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 #: 47PM0217R0016.
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 Point of Contact: Dr. Richard L. Brooks, PBS, (202) 257-8863
DOS Point of Contact: Bryan E. Patterson, A/OPR/RPM/DC, (202) 647-9441
Purpose of Visit: Solicitation Proposal Bid & Site Visit
Visit Location: Harry S. Truman 3301 C Street NW, Washington, DC
Dates of Visit: (10/31/2017 – 10/30//2018)
Onsite Person to Visit: Bryan E. Patterson, A/OPR/RPM/DC, (202) 647-9441
Facility Clearance: Required; CAGE Code: Required DSS Your DSS Cognizant Security Office Address:
Sincerely, (Signature) Print Name Facility Security Officer
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