Att J-0200000-05 5512 7-31-2027.pdf
PDF 86 KB Posted
- Attached to
- Naval Weapons Station Earle Environmental Laboratory Services Federal contract opportunity
- Solicitation number
- N4008526R0013
About this file
This document is a Restricted Area Access Request Form (NWSEARLEINST 5530.12C, Revision 7-2024) used by the Department of the Navy for Naval Weapons Station (NWS) Earle. The form is designed for contractors and visitors seeking access to restricted areas, requiring detailed personal information including name, contact details, date of birth, CAC or driver's license number, and contract details. The form includes sections for applicant information, government representative approval, and verification of access clearance, with specific checkboxes for access to areas such as camera, ordnance, pier, and specific zones C-33 and C-34. The form emphasizes that the requesting company assumes full responsibility for the individual while on naval station property and must return the badge upon contract completion or termination of assignment.
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Text version
NWSEARLEINST 5530.12C
TAB R
CUI
RESTRICTED AREA ACCESS REQUEST FORM REVISION 7-2024
PLEASE ALLOW 5 BUSINESS DAYS FOR PROCESSING
APPLICANT INFORMATION
VCC Results:
CLEARED NOT CLEARED
Signature/Date
Pass/Badge Number Issued By (Print) Signature/Date
CUI
CONTROLLED BY: DEPARTMENT OF THE NAVY
CUI CATEGORY: PRVCY
DISTRIBUTION/DISSEMINATION CONTROL: FEDCON
POC: VISTOR CONTROL CENTER NWSE
Name:
Address:
City: State: Zip:
Phone Number: Date of Birth:
CAC or Driver’s license number: CAC Expiration:
Last 4 of Social Security number:
Prime Contractor Company Phone Number Sub Contractor Name Phone Number
Contract Expiration Date:
(Last) (First) (Middle)
***PRIVACY ACT OF 1974 APPLIES*** (SEE NOTE BELOW)
GOVERNMENT REPRESENTATIVE ONLY
RESTRICTED AREA ACCESS APPROVAL
CAMERA
Security Representative Signature and Date
ORDNANCE PIER C-33 C-34
1. It is requested that a badge/pass be issued to the person listed above. It is understood that this command/company will be responsible for said pass and it will be returned as the termination of assignment/employment or completion of present contract.
2. It is further represented that this command/company assumes responsibility for the person listed above while they are on the property of Naval Weapons Station (NWS) Earle during the period for which the badge/pass will be issued.
Government Representative (Print) Phone Number Signature/Date
Slide 1
| Last Name: |
| First Name: |
| Middle Name: |
| Address: |
| City: |
| State: |
| Zipcode: |
| Phone: |
| Date of Birth: |
| CAC or DL#: |
| CAC Exp: |
| Last 4 SSN: |
| Prime Contractor: |
| Prime Phone: |
| Sub Phone: |
| Contract Exp: |
| Camera: Off |
| Ordnance: Off |
| Pier: Off |
| C33: Off |
| C34: Off |
| Sponsor: |
| Sponsor Phone: |
| Cleared: Off |
| Not Cleared: Off |
| Pass/Badge #: |
| Issuer: |
| Clear Form: |
File details come from the government source that posted it. Updated .