7_Attachment 5 - NSWCCORDIV 5530_11.pdf

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NSWCCORDIV 5530/11 (REV. 10-16)

PAGE of

NSWC CORONA

PREVIOUS EDITIONS ARE OBSOLETE

VISITOR NOTIFICATION

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041; OPNAVINST 5530.14E, Navy Physical Security.

PURPOSE(S): To control physical access to Naval Surface Warfare Center, Corona Division controlled information, facilities, or areas over which DoD, DON has security responsibilities by identifying or verifying an individual through the use of biometric databases and associated data processing/information services for designated populations for purposes of protecting U.S./Coalition/allied government/national security areas of responsibility and information; to issue badges, and retrieve passes upon separation; to maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/exit times of personnel.

ROUTINE USE(S): To designated contractors, Federal agencies, and foreign governments for the purpose of granting personnel access to Corona Division areas and spaces.

DISCLOSURE: Providing registration information is voluntary. Failure to provide requested information may result in denial of access to DoD installations, facilities and buildings.

1. SELECT THE TYPE OF VISITOR NOTIFICATION:

17. EQUIPMENT (Notify CIO or Security Manager if either item is checked):

16. CLASSIFICATION OF VISIT/MEETING:

19. MULTIMEDIA CHECK LIST:

18. SECURITY CHECK LIST:

VISITOR INFO (COMPLETED BY CORONA DIVISION POC)

OFFICE USE ONLY

CITIZENSHIP

RANK/PAYBAND/

GS GRADE

CAC CARD

ACTIVITY NAME, CITY, STATE

CLEARANCE

JPASEXPIRATION DATE

BADGE #

PIN #

ORGANIZATION NAME, CITY, STATE, ZIP

CIV/MIL/CTR

CAC CARD

U.S. CITIZEN

CLEARANCE

JPAS EXPIRATION DATE

BADGE #

PIN #

THIS IS A CAC SIGNED ELECTRONIC FORM AND THE RECORD COPY MUST BE MAINTAINED ELECTRONICALLY. CAC SIGNED PRINTED VERSIONS OF THIS FORM ARE NOT VALID RECORDS. IF THE FORM CANNOT BE CAC SIGNED, ALL SIGNATURES MUST BE PEN & INK. IF PEN & INK AND CAC SIGNATURES ARE MIXED ON THE FORM, THE FORM IS INVALID. RECORD COPIES OF THIS FORM WILL BE MAINTAINED BY CODE 105 IAW SECNAV M-5210.1.

9.0.0.2.20120627.2.874785

US

US