fletc_form_121-00-02_visitor_access_request.pdf

DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

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

5. Dual Citizen: Yes No 6. Place of Birth (City and State): 7. Date of Birth:

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. 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 Frequent Vendor One Time Vendor PO Staff 5 Day or Less Visitor 5 Day or Less Contractor Frequent Visitor Transporter/CU/FLETC REC

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: Work End Date:

SECTION C - To be Completed by FLETC Security

1. NCIC Check:

No Results Found Results Found

ARN:

FBI Number:

2. Type of Badge to be Issued::

5 Day or Less Contractor

Frequent Vendor

Frequent Visitor

5 Day or Less Visitor

Graduation Guest

One Time Vendor

PO Staff

Transporter/CU/FLETC REC

3. OSPR Decision: Approved Denied

Approved Start Date: Approved Expiration Date:

OSPR Initials: Date:

Notes:

FLETC Form 121-00-02 (4/20) Page 1 of 1

DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

VISITOR ACCESS REQUEST

Department of Homeland Security Federal Law Enforcement Training Centers BADGE application 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 (Last, First, Middle)

2. Residential Address:

3. Driver's License:

(* If not a U.S. Citizen, you must complete the DHS Form 11055 or 11059)

5. Dual Citizen:

8. Gender:

10. Current PIV/CAC Card:

11. Contact Information:

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

2. Type of access requested for Applicant:

6. Requested Access Dates:

SECTION C - To be Completed by FLETC Security

1. NCIC Check:

2. Type of Badge to be Issued::

3. OSPR Decision:

FLETC Form 121-00-02 (4/20) 9.0.0.2.20120627.2.874785