VAR FLETC Form 121-00-02 (723).pdf

DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

VISITOR & VENDOR ACCESS REQUEST

Privacy Act Statement:

Authority: 5 U.S.C. 301; the Homeland Security Act, codified in Title 6 of the U.S. Code; 44 U.S.C. 3101; and Executive Order (EO) 9397; EO 12968; and Federal Property Regulations, issued July 2002.

Purpose: The purpose for collecting and maintaining this information is to allow individuals access associated with DHS/FLETC facilities and perimeter access control, as well as visitor security and management.

Routine Uses: System of Records Notice (SORN) DHS/ALL-024 located at https://www.govinfo.gov/content/pkg/FR-2010-02-03/html/2010-2206.htm.

Disclosure: Disclosure of this information is voluntary. Failure to provide requested information may result in denial of access to the FLETC property.

SECTION A - To be completed by Applicant

1. Applicants Full Name:

(Last, First, Middle)

Aliases Used (nicknames, maiden names, etc):

2. Residential Address: Street Address:

City, State, Zip code:

3. Driver's License: State: Driver's License #: 4. Date of Birth:

5. Place of Birth (City and State or Country): 6. Dual Citizen of another Country?: Yes No

7. Country of Citizenship (List all that apply * ): (* If not a U.S. Citizen, you must complete the DHS Form 11055 or 11059)

8. Gender Male Female 9. Social Security #: 10. Current PIV/CAC Card: Yes No

11. Contact Information: Home or cell phone number: E-mail:

12. Last Date on FLETC: 13. Date Completed:

SECTION B - To be Completed by Sponsor (Must be a Federal Employee)

1. Sponsor Name: Agency:

E-mail Address: Office/Cell Number:

2. Type of access requested for Applicant: Graduation Guest One Time Vendor Frequent Vendor Transporter One Time Visitor 5 Day or Less Contractor

3. Class Number (if a Graduation Guest):

4. Relationship to Applicant (if a Visitor):

5. Company Name (if a Vendor or a 5 Day or Less CTR):

6. Requested Access Dates: Start Date: End Date:

SECTION C - Type of Access (To be Completed by FLETC Security)

1. Type of Access:

NCIC Only-Paper Pass: Fingerprints Required - Prox Badge: No NCIC - Prox Badge: NCIC Only-Prox Badge:

5 day or less contractor PO Staff

One Time Visitor PO Staff (If no PIV/CAC)

Frequent Vendor

Transporter

One Time Vendor

Graduation Guest

2. NCIC Check:

No Results Found Results Found

ARN:

FBI Number:

Notes:

FLETC Form 121-00-02 (7/23) Page 1 of 1

Frequent Visitor PO Staff

Frequent Visitor http://www.govinfo.gov/content/pkg/FR-2010-02-03/html/2010-2206.htm DSimmons Underline