Base E-City Visitor Request (2).pdf

PDF 245 KB Posted Dec 14, 2023

Attached to: Base Elizabeth City Water Quality Testing Service Federal contract opportunity
Solicitation number: 70Z08124QELIZ0004
Issued by: Department of Homeland Security US Coast Guard

About this file

Written by GovTribe AI · Dec 21, 2023

This document is a visitor request form for Base Elizabeth City. The form collects personal information such as name, date of birth, driver's license, citizenship, and phone number from visitors and requires the purpose and location of visits as well as arrival and departure times. It notes foreign visitors must submit requests at least 30 days in advance and provides points of contact for different commands at the base. The related federal contract opportunity is a solicitation from the Department of Homeland Security Coast Guard for water quality testing services at Base Elizabeth City. It includes the solicitation number but no other salient details.

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SF18_Watertreatmant.pdf	PDF	Dec 12, 2023
SF1449_Clauses_and_Provisions_Supply_and_Service_JUN2023.docx	DOCX document	Dec 12, 2023

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Base Elizabeth City Visitor Request

CGPD Page 1

For questions, contact your Command Security Officer or Base Police at (252) 335-6588.

All requests shall be submitted no later than seventy-two hours prior to visit.

Reference BASEECITYINST 5512.1B for additional information and requirements.

Visitor Information:

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

Last Name: First Name, MI:

(full first name)

DOB:

(mm/dd/yyyy)

Driver’s License:

State and Number

Citizenship:

(US, Foreign, Perm. Res.)

Phone Number:

Visitor(s) Organization:

Purpose of Visit:

Place of Visit:

Arrival: Time: Date:

Departure: Time: Date:

Sponsor’s Name:

Sponsor’s Command/Affiliation:

Sponsor’s Contact Info: Phone: Email:

Comments:

(30 Day request must be specifically requested and is not guaranteed) Foreign visitors must be submitted no less than thirty days prior to an official visit.

Coast Guard Foreign Visit Program For more information and/or guidance, contact your Command Security Officer.

Base Elizabeth City and Tenant Command CSOs:

Base Elizabeth City: MEC Hess, Thomas (252) 335-6855 Aviation Technical Training Center: AETC Wood, Christopher (252) 335-6917 Aviation Logistics Center: Mr. Smith, Stephen (252) 384-7173 Air Station Elizabeth City: OSC Brancaleone, Paul (252) 335-6761 Station Elizabeth City: BM1 Garvey, John (252) 335-6086 C27J Asset Project Office: AETCS Jones, Jeffrey (252) 335-6279 https://cg.portal.uscg.mil/units/cgdcoi/cg-foreign-visits-program/SitePages/Home.aspx

Base Elizabeth City Visitor Request

CGPD Page 2

Last Name: First Name, MI:

(full first name)

DOB:

(mm/dd/yyyy)

Driver’s License:

State and Number

Citizenship:

(US, Foreign, Perm. Res.)

Phone Number:

INFORMATION REQUIRED BY THE PRIVACY ACT OF 1974

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: To collect and maintain records associated with Department of Homeland Security (DHS) facility and perimeter access control, including access to DHS information technology and access to classified facilities, as well as visitor security and management.

ROUTINE USES: To conduct a criminal background check to substantiate the identity and existence of any outstanding warrants in order to determine eligibility for access to DHS facilities.

DISCLOSURE IS VOLUNTARY: However failure to furnish information requested may result in delay or inability to access DHS facilities.

Last NameRow1:

First Name MI full first nameRow1:

DOB mmddyyyyRow1:

Drivers License State and NumberRow1:

Citizenship US Foreign Perm ResRow1:

Phone NumberRow1:

Last NameRow2:

First Name MI full first nameRow2:

DOB mmddyyyyRow2:

Drivers License State and NumberRow2:

Citizenship US Foreign Perm ResRow2:

Phone NumberRow2:

Last NameRow3:

First Name MI full first nameRow3:

DOB mmddyyyyRow3:

Drivers License State and NumberRow3:

Citizenship US Foreign Perm ResRow3:

Phone NumberRow3:

Last NameRow4:

First Name MI full first nameRow4:

DOB mmddyyyyRow4:

Drivers License State and NumberRow4:

Citizenship US Foreign Perm ResRow4:

Phone NumberRow4:

Last NameRow5:

First Name MI full first nameRow5:

DOB mmddyyyyRow5:

Drivers License State and NumberRow5:

Citizenship US Foreign Perm ResRow5:

Phone NumberRow5:

Last NameRow6:

First Name MI full first nameRow6:

DOB mmddyyyyRow6:

Drivers License State and NumberRow6:

Citizenship US Foreign Perm ResRow6:

Phone NumberRow6:

Last NameRow7:

First Name MI full first nameRow7:

DOB mmddyyyyRow7:

Drivers License State and NumberRow7:

Citizenship US Foreign Perm ResRow7:

Phone NumberRow7:

Last NameRow8:

First Name MI full first nameRow8:

DOB mmddyyyyRow8:

Drivers License State and NumberRow8:

Citizenship US Foreign Perm ResRow8:

Phone NumberRow8:

Last NameRow9:

First Name MI full first nameRow9:

DOB mmddyyyyRow9:

Drivers License State and NumberRow9:

Citizenship US Foreign Perm ResRow9:

Phone NumberRow9:

Purpose of Visit:

Place of Visit:

Time:

Date:

Time_2:

Date_2:

Sponsors Name:

Sponsors CommandAffiliation:

Phone:

Email:

Last NameRow1_2:

First Name MI full first nameRow1_2:

DOB mmddyyyyRow1_2:

Drivers License State and NumberRow1_2:

Citizenship US Foreign Perm ResRow1_2:

Phone NumberRow1_2:

Last NameRow2_2:

First Name MI full first nameRow2_2:

DOB mmddyyyyRow2_2:

Drivers License State and NumberRow2_2:

Citizenship US Foreign Perm ResRow2_2:

Phone NumberRow2_2:

Last NameRow3_2:

First Name MI full first nameRow3_2:

DOB mmddyyyyRow3_2:

Drivers License State and NumberRow3_2:

Citizenship US Foreign Perm ResRow3_2:

Phone NumberRow3_2:

Last NameRow4_2:

First Name MI full first nameRow4_2:

DOB mmddyyyyRow4_2:

Drivers License State and NumberRow4_2:

Citizenship US Foreign Perm ResRow4_2:

Phone NumberRow4_2:

Last NameRow5_2:

First Name MI full first nameRow5_2:

DOB mmddyyyyRow5_2:

Drivers License State and NumberRow5_2:

Citizenship US Foreign Perm ResRow5_2:

Phone NumberRow5_2:

Last NameRow6_2:

First Name MI full first nameRow6_2:

DOB mmddyyyyRow6_2:

Drivers License State and NumberRow6_2:

Citizenship US Foreign Perm ResRow6_2:

Phone NumberRow6_2:

Last NameRow7_2:

First Name MI full first nameRow7_2:

DOB mmddyyyyRow7_2:

Drivers License State and NumberRow7_2:

Citizenship US Foreign Perm ResRow7_2:

Phone NumberRow7_2:

Last NameRow8_2:

First Name MI full first nameRow8_2:

DOB mmddyyyyRow8_2:

Drivers License State and NumberRow8_2:

Citizenship US Foreign Perm ResRow8_2:

Phone NumberRow8_2:

Last NameRow9_2:

First Name MI full first nameRow9_2:

DOB mmddyyyyRow9_2:

Drivers License State and NumberRow9_2:

Citizenship US Foreign Perm ResRow9_2:

Phone NumberRow9_2:

Last NameRow10:

First Name MI full first nameRow10:

DOB mmddyyyyRow10:

Drivers License State and NumberRow10:

Citizenship US Foreign Perm ResRow10:

Phone NumberRow10:

Last NameRow11:

First Name MI full first nameRow11:

DOB mmddyyyyRow11:

Drivers License State and NumberRow11:

Citizenship US Foreign Perm ResRow11:

Phone NumberRow11:

Last NameRow12:

First Name MI full first nameRow12:

DOB mmddyyyyRow12:

Drivers License State and NumberRow12:

Citizenship US Foreign Perm ResRow12:

Phone NumberRow12:

Last NameRow13:

First Name MI full first nameRow13:

DOB mmddyyyyRow13:

Drivers License State and NumberRow13:

Citizenship US Foreign Perm ResRow13:

Phone NumberRow13:

Last NameRow14:

First Name MI full first nameRow14:

DOB mmddyyyyRow14:

Drivers License State and NumberRow14:

Citizenship US Foreign Perm ResRow14:

Phone NumberRow14:

Last NameRow15:

First Name MI full first nameRow15:

DOB mmddyyyyRow15:

Drivers License State and NumberRow15:

Citizenship US Foreign Perm ResRow15:

Phone NumberRow15:

Last NameRow16:

First Name MI full first nameRow16:

DOB mmddyyyyRow16:

Drivers License State and NumberRow16:

Citizenship US Foreign Perm ResRow16:

Phone NumberRow16:

Last NameRow17:

First Name MI full first nameRow17:

DOB mmddyyyyRow17:

Drivers License State and NumberRow17:

Citizenship US Foreign Perm ResRow17:

Phone NumberRow17:

Last NameRow18:

First Name MI full first nameRow18:

DOB mmddyyyyRow18:

Drivers License State and NumberRow18:

Citizenship US Foreign Perm ResRow18:

Phone NumberRow18:

Last NameRow19:

First Name MI full first nameRow19:

DOB mmddyyyyRow19:

Drivers License State and NumberRow19:

Citizenship US Foreign Perm ResRow19:

Phone NumberRow19:

Last NameRow20:

First Name MI full first nameRow20:

DOB mmddyyyyRow20:

Drivers License State and NumberRow20:

Citizenship US Foreign Perm ResRow20:

Phone NumberRow20:

Last NameRow21:

First Name MI full first nameRow21:

DOB mmddyyyyRow21:

Drivers License State and NumberRow21:

Citizenship US Foreign Perm ResRow21:

Phone NumberRow21:

Last NameRow22:

First Name MI full first nameRow22:

DOB mmddyyyyRow22:

Drivers License State and NumberRow22:

Citizenship US Foreign Perm ResRow22:

Phone NumberRow22:

Last NameRow23:

First Name MI full first nameRow23:

DOB mmddyyyyRow23:

Drivers License State and NumberRow23:

Citizenship US Foreign Perm ResRow23:

Phone NumberRow23:

Last NameRow24:

First Name MI full first nameRow24:

DOB mmddyyyyRow24:

Drivers License State and NumberRow24:

Citizenship US Foreign Perm ResRow24:

Phone NumberRow24:

Last NameRow25:

First Name MI full first nameRow25:

DOB mmddyyyyRow25:

Drivers License State and NumberRow25:

Citizenship US Foreign Perm ResRow25:

Phone NumberRow25:

Last NameRow26:

First Name MI full first nameRow26:

DOB mmddyyyyRow26:

Drivers License State and NumberRow26:

Citizenship US Foreign Perm ResRow26:

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Last NameRow27:

First Name MI full first nameRow27:

DOB mmddyyyyRow27:

Drivers License State and NumberRow27:

Citizenship US Foreign Perm ResRow27:

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First Name MI full first nameRow28:

DOB mmddyyyyRow28:

Drivers License State and NumberRow28:

Citizenship US Foreign Perm ResRow28:

Phone NumberRow28:

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First Name MI full first nameRow29:

DOB mmddyyyyRow29:

Drivers License State and NumberRow29:

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First Name MI full first nameRow30:

DOB mmddyyyyRow30:

Drivers License State and NumberRow30:

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File details come from the government source that posted it. Updated Dec 14, 2023.