Appendix H - STA_Form17_FEB2024.v3.0_Single.pdf

VISITOR NOTIFICATION/TEMPORARY SECURITY IDENTIFICATION BADGE

U.S. ARMY GARRISON - DETROIT ARSENAL

(Governing Directive is AR 190-13)

PRIVACY ACT STATEMENT

AUTHORITY: U S C

PRINCIPAL PURPOSE(S): To provide s

ROUTINE USE(S): " Blanket Routine Uses" are set forth at the beginning of the Army’s compilation systems or record notices.

DISCLOSURE: Voluntary; however, failure to provide all the requested information will result in the denial of an authorized access pass (or equivalent) and denial of entry to Army Installations.

IMPORTANT NOTE: It is your responsibility to give the Visitor Control Center (VCC) advance notice of the pending visits to avoid delays in the in-processing of your visitors. Complete instructions for processing this form can be obtained at 586-282-5757.

Foreign National/Non-US Citizen Visits:

1. For visit authorization first send the completed form to TACOM-LCMC, G-2. The request must be received seven (7) business days prior to the visit for approval.

2. The G-2 will return the form to you for further coordination with the VCC.

3. Send the completed STA Form 17 with authorization from the G-2 to POC at VCC.

DATE(S) OF VISIT/Period of Performance: Please provide beginning and ending dates for the meeting/visit and the contract number. Ending date will be the end date of the visit or contract, or the expiration date of the sponsor's credentials, whichever occurs first. In the "Additional Information/Remarks" section please provide pertinent information;

i.e. "The visitors will arrive at 0700"; or "This visitor is a citizen of country."

Visit requests must be received by the VCC four (4) business days prior to the scheduled visit. For large group visits (11-19 individuals) there is a seven (7) business day lead time; and for groups larger than 20 the lead time is 14 business days notification prior to visit. Sponsors should direct visitors and contractors to receive their badge at the VCC Bldg. 232, Monday through Friday, from 0700-1400.

KEY TO VISITOR'S INFORMATION (BOTTOM OF FORM):

NAME

Last name, first name, middle initial, suffixes i.e., Jr.., Sr.., Dr., etc. of visitor. Beneath the visitor's name enter Business' name or government organization name.

DRIVER'S LICENSE #

Visitor's driver license number. Below that, the State that issued the license and expiration date.

DOB (MM/DD/YYYY) Date of Birth for the visitor, ex: 04/14/2004

FN? Y/N If Non-US Citizen/Foreign National - enter "Y"; if not enter "N"

G-2 APPROVED? Y/N

If the answer to "FN?" above is yes, you must get G-2 approval. Not having G-2 approval will delay your visitor and perhaps be turned away at the VCC.

DoD EMPLOYEE? Y/N Is the visitor a current or past Department of Defense employee? Yes or No. If yes, see below

CAC/MIL ID? Select "Y" or "N" if the visitor has a Common Access Card (CAC) or Military ID Card.

CAC EXP. DATE

Date of Sponsor CAC expiration must be completed. Approved access can't exceed the sponsor's CAC expiration.

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VISITOR NOTIFICATION/TEMPORARY SECURITY IDENTIFICATION BADGE

U.S. ARMY GARRISON - DETROIT ARSENAL

(Governing Directive is AR 190-13)

GOVERNMENT SPONSOR(S) - ALL VISITORS REQUIRE A SPONSOR

Primary POC: Alternate POC:

Name: Name:

Phone #: Phone #:

Office: Office:

Provide 2 Points of Contact (POC) with different phone numbers OR provide an office number AND cell phone number so we can contact you if necessary

DATE(S) OF VISIT/PERIOD OF PERFORMANCE

(Ending date will be the end date of the visit or contract, or the expiration date of the sponsor's credentials, whichever occurs first)

Beginning Date: End Date: Contract Number:

Additional Information/Remarks:

VISITOR INFORMATION

If your visitor is a Foreign National, you MUST coordinate the visit with the TACOM G-2 Office. Failure to do so will result in your visitor being denied entrance to the Installation. Please mark in the "FN" column below with "Y" (yes) and "N" (no) indicating whether your visitor is a Foreign National AND if the G-2 office approved the visit. YOU are responsible for escorting a Foreign National visitor at ALL TIMES.

NAME & BUSINESS DRIVER'S LICENSE INFORMATION Approvals

Name: (Last, First MI (Jr./Sr.) Driver's License # FN? YES NO

G-2 Signature

Business Name/Govt Organization State of Issue Exp. Date DOB DoD Employee? YES NO

CAC/Mil ID? YES NO

USE STA FORM 17-1, CONTINUATION SHEET, FOR ADDITIONAL VISITOR APPROVAL REQUESTS

SPONSOR ACKNOWLEDGEMENT AND SIGNATURE

By submission of this form the government sponsor acknowledges the responsibility of the conduct of the visitor and the return of the Installation security badge to the Visitor Control Center (VCC).

Do not electronically sign form until all visitor’s data has been entered. Electronic signature will lock the form and prevent any changes from being made.

CAC Exp. Date:

Sponsor Signature:

FOR VISITOR CONTROL CENTER USE ONLY

VCC ASSOCIATE: Indicate completion of name check by NCIC by selecting the appropriate response from the drop-down list. If no derogatory information is on file, approve visit request/badge application. File NCIC transaction record alphabetically for each day. Send copy of approved visit request/badge application to government sponsor/POC listed on form. If derogatory information is obtained, notify Police Operations for processing requirements.

V : Signature:

Date: STA 17 :

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