Access Request Form.pdf

DEPARTMENT OF HOMELAND SECURITY

FEDERAL EMERGENCY MANAGEMENT AGENCY

FACILITY ACCESS REQUEST

INSTRUCTIONS

1. To apply for access into FEMA controlled facilities, all applicants must TYPE or PRINT the applicable parts of this form. Fill out, sign and return to the point of contact. Part III of this form must be completed and signed by the person applying.

2. The point of contact must sign and forward completed form to the Facility Security Manager.

3. Applicants requesting access to be programmed onto an existing PIV Card must know their PIN Number.

Authorized personnel may have access to rooms/suite entry door within FEMA space only after coordination/endorsements from the servicing program office of the space in question and the Office of the Chief Security Officer (OCSO). If you have questions, you can call the OCSO at

(202) 646-2900.

4. FEMA Employees or Contractors: Complete Part I.

Visitors without an existing PIV Card: Complete Parts I and II.

Guests requesting access for an existing PIV Card: Complete Parts I, II, and III.

PART I – TO BE COMPLETED BY THE RESPONSIBLE OFFICE

FULL NAME OF APPLICANT (Last, First, Middle, and Maiden if applicable) RESPONSIBLE PROGRAM OFFICE

SITE(S) TO BE ACCESSED BY INDIVIDUAL FREQUENCY OF ACCESS REQUIRED (Check One)

Daily Weekly Monthly Other

LENGTH OF ACCESS REQUIREMENT

Start Date:

End Date:

ROOM/SUITE ENTRY DOOR TO BE ACCESSED BY

INDIVIDUAL (IF APPLICABLE)

GOVERNMENT INFORMATION SYSTEM ACCESS REQUIRED?

YES (CHECK ONE) NO

POC PHONE NO.

GOVERNMENT POC (Last, First, Middle) SIGNATURE OF POINT OF CONTACT

PART II – TO BE COMPLETED BY APPLICANT

CURRENTLY HAVE A PIV, PIV-I, or CAC CARD? YES (CHECK ONE) NO IF YES, WHAT ISSUING AGENCY?

DATE OF BIRTH (MM/DD/YYYY) SEX

MALE

FEMALE

HEIGHT WEIGHT SOCIAL SECURITY

NUMBER

DRIVER’S LICENSE # AND STATE

PLACE OF BIRTH (CITY, STATE, COUNTRY) DO YOU HOLD A U.S. CITIZENSHIP STATUS?

YES (CHECK ONE) NO

IF NO, PROVIDE ALIEN REGISTRATION #:

ARE YOU A NATURALIZED CITIZEN?

YES (CHECK ONE) NO

IF YES, PROVIDE NATURALIZATION DATE/ALIEN #:

HAIR COLOR EYE COLOR ETHNICITY

WHITE ASIAN HISPANIC OR LATINO PACIFIC ISLANDER

AFRICAN AMERICAN AMERICAN INDIAN OR ALASKAN NATIVE OTHER:___________________

HOME ADDRESS (STREET, CITY, STATE, ZIP) TELEPHONE NUMBER

HOME:

WORK:

NAME OF EMPLOYER ADDRESS OF EMPLOYER (Street Address, City, State, ZIP) NAME OF SUPERVISOR & PHONE NO.

PRINTED NAME OF APPLICANT SIGNATURE OF APPLICANT (see PRIVACY ACT STATEMENT on back) DATE

PART III – TO BE COMPLETED BY ORGANIZATION SECURITY OFFICER

* MUST be completed for any visitors/guests requiring access to classified information.

ORGANIZATION SECURITY OFFICER NAME AND AGENCY SIGNATURE DATE

CONTRACT NO. (IF APPLICABLE) CONTRACT EXPIRATION

DATE (IF APPLICABLE)

CURRENT INVESTIGATION ON FILE?

YES (CHECK ONE) NO

INVESTIGATION TYPE

DATE OF INVESTIGATION INVESTIGATING AGENCY CLEARANCE LEVEL (IF APPLICABLE) DATE GRANTED SPECIAL ACCESS (IF APPLICABLE)

SI-TK-G DATE BRIEFED:

HCS DATE BRIEFED:

PART IV – TO BE COMPLETED BY THE PHYSICAL ACCESS CONTROL SYSTEM (PACS) ENROLLMENT OFFICIAL ENROLLMENT OFFICIAL NAME ENROLLMENT OFFICIAL SIGNATURE DATE ACCESS GRANTED BADGE EXPIRE DATE

R4-Mission Support Division

R4-Atlanta-Rhodes

PRIVACY ACT STATEMENT:

All information requested on the Facility Access Request and release statement is collected under authority derived from 18 USC 3056 and executive order 9397. The routine uses of information requested include referral to other federal, state, local agencies for determining suitability for access to secure areas, and/or sensitive, unclassified material of FEMA.

Submission of the information is voluntary, however, failure to provide information requested may prohibit processing and cause denial of access to secure areas or sensitive material protected by FEMA. Disclosure of your social security number will be no cause for denial of any right, benefit, or privilege provided by law.

This release when presented by a duly authorized representative of the Federal Emergency Management Agency (FEMA) will constitute my consent and authority to examine and obtain copies and abstracts of records, as well as receive statements of information concerning my background. Specifically, I hereby authorize the release of Federal/State/Local police and criminal records to FEMA by applying my signature on the designated line below. This authorization is given in connection with the investigative procedures being conducted relative to my contractual services with FEMA.

NOTE: I understand that any false statement on any part of my application may be grounds for denying me access into Federal Emergency Management Agency controlled facilities, and/or grounds for prosecution under Title18 USC 1001.