Amendment 0004 Attachment CG Base LALB Visitor Request.pdf

PDF 367 KB Posted Jun 10, 2020

Attached to: CONSTRUCT OPC HOMEPORT BASE LOS ANGELES/LONG BEACH AT U. S. COAST GUARD STATION, SAN PEDRO, CA
Solicitation number: 70Z05020ROPCLA1
Issued by: Department of Homeland Security US Coast Guard

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Base LA/LB Visitor Request For questions contact Base Security Division at (424) 533-8046. All requests shall be submitted no later than forty-eight hours prior to visit.

Visitor(s) Information:

(For additional visitors, use page two. If more space is needed, attach another document with your request.)

Last Name: First Name, MI:

Visitor(s) Organization:

Purpose of Visit:

Place of Visit:

Time/Date of Arrival:

Time/Date of Departure:

Sponsor’s Name:

Sponsor’s Contact Info: E-Mail:

Comments:

* Foreign visitors must be cleared no later than thirty days prior to an official visit. For more information and/or guidance, contact your Command Security Officer.

* Valid photo ID consists of the following: State drivers license, state identification card, TWIC card, government issued identification, and federal/state issued credentials.

Invalid photo ID is an ID that is expired, or a drivers license from a non-real-ID compliant state.

* For the most recent list, please visit: http://www.dhs.gov/secure-drivers-licenses#1

DOB: Valid photo ID U.S. Citizen:Y/N

Phone:

PRIVACY NOTICE: When filled in, this document may contain Personally Identifiable Information or Sensitive Personally Identifiable Information and must be protected accordingly per the Privacy Act of 1974, 5 USC § 552a. Any review, use, disclosure, or retention by others is other than the intended recipient is strictly prohibited. If you are not an intended recipient, please contact the sender and delete this email, any attachments, and all copies.

Last Name: First Name, MI: DOB: *US Citizen Y/N

Any review, use, disclosure, or retention by others is other than the intended recipient is strictly prohibited. If you are not an intended recipient, please contact the sender and delete this email, any attachments, and all copies.

Last NameVisitors Information For additional visitors use page two If more space is needed attach another document with your request_2:

First Name MIVisitors Information For additional visitors use page two If more space is needed attach another document with your request_2:

DOBVisitors Information For additional visitors use page two If more space is needed attach another document with your request_2:

Valid photo ID SSNVisitors Information For additional visitors use page two If more space is needed attach another document with your request_2:

US Citizen Yes NoVisitors Information For additional visitors use page two If more space is needed attach another document with your request_2:

Last NameVisitors Information For additional visitors use page two If more space is needed attach another document with your request_3:

First Name MIVisitors Information For additional visitors use page two If more space is needed attach another document with your request_3:

DOBVisitors Information For additional visitors use page two If more space is needed attach another document with your request_3:

Valid photo ID SSNVisitors Information For additional visitors use page two If more space is needed attach another document with your request_3:

US Citizen Yes NoVisitors Information For additional visitors use page two If more space is needed attach another document with your request_3:

Last NameVisitors Information For additional visitors use page two If more space is needed attach another document with your request_4:

First Name MIVisitors Information For additional visitors use page two If more space is needed attach another document with your request_4:

DOBVisitors Information For additional visitors use page two If more space is needed attach another document with your request_4:

Valid photo ID SSNVisitors Information For additional visitors use page two If more space is needed attach another document with your request_4:

US Citizen Yes NoVisitors Information For additional visitors use page two If more space is needed attach another document with your request_4:

Last NameVisitors Information For additional visitors use page two If more space is needed attach another document with your request_5:

First Name MIVisitors Information For additional visitors use page two If more space is needed attach another document with your request_5:

DOBVisitors Information For additional visitors use page two If more space is needed attach another document with your request_5:

Valid photo ID SSNVisitors Information For additional visitors use page two If more space is needed attach another document with your request_5:

US Citizen Yes NoVisitors Information For additional visitors use page two If more space is needed attach another document with your request_5:

Last NameVisitors Information For additional visitors use page two If more space is needed attach another document with your request_6:

First Name MIVisitors Information For additional visitors use page two If more space is needed attach another document with your request_6:

DOBVisitors Information For additional visitors use page two If more space is needed attach another document with your request_6:

Valid photo ID SSNVisitors Information For additional visitors use page two If more space is needed attach another document with your request_6:

US Citizen Yes NoVisitors Information For additional visitors use page two If more space is needed attach another document with your request_6:

Visitors Organization:

Purpose of Visit: Site walk for: CONSTRUCT OPC HOMEPORT BASE LOS ANGELES/LONG BEACH

Place of Visit: Base LALB

TimeDate of Arrival:

TimeDate of Departure:

Sponsors Name: Paul Nelson (Assistant Facility Eng)

Comments: Contractors to visit Base LA/LB for bid on future OPC construction project.

Last NameRow1:

First Name MIRow1:

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US Citizen YNRow1:

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Phone: 207-272-2478 (cell) or 310-521-6014 (office)

EMail: Paul.L.Nelson@uscg.mil

Last NameVisitors Information For additional visitors use page two If more space is needed attach another document with your request:

First Name MIVisitors Information For additional visitors use page two If more space is needed attach another document with your request:

DOBVisitors Information For additional visitors use page two If more space is needed attach another document with your request:

Valid photo ID SSNVisitors Information For additional visitors use page two If more space is needed attach another document with your request:

US Citizen Yes NoVisitors Information For additional visitors use page two If more space is needed attach another document with your request:

SUBMIT:

Last NameVisitors Information For additional visitors use page two If more space is needed attach another document with your request_1:

First Name MIVisitors Information For additional visitors use page two If more space is needed attach another document with your request_1:

DOBVisitors Information For additional visitors use page two If more space is needed attach another document with your request_1:

Valid photo ID SSNVisitors Information For additional visitors use page two If more space is needed attach another document with your request_1:

US Citizen Yes NoVisitors Information For additional visitors use page two If more space is needed attach another document with your request_1:

File details come from the government source that posted it. Updated Jun 10, 2020.