Attachment 0005 C5ISR Center Visitor Request Form.pdf

556 KB Posted

Attached to
C5ISR Center Infrastructure Management Contract (C5IMC)
Solicitation number
W56KGU26RC1MC
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This document is a C5ISR Center Visit Request form (Version 3.2.9, October 2024) used to process visitor access to C5ISR facilities for uncleared personnel. The form is required exclusively for visitors with no active security clearance; visitors with active clearances in DISS/Scattered Castles require submission of a DISS/M3 VAR by their owning organization instead. The form applies to three primary locations: Aberdeen Proving Grounds, Maryland; Joint Base McGuire-Dix-Lakehurst, New Jersey; and Fort Belvoir, Virginia, with separate SMO codes provided for non-SCI and SCI access requests.

The form consists of two primary sections completed by different parties. The visitor section requires personal information including name, citizenship status, dual citizenship disclosure, organization affiliation (with classified agency affiliations excluded), visitor type, and email address. The Point of Contact (POC) sponsor section requires the POC name, organization, phone contact, site location, building/room numbers to be visited, arrival and departure dates with times, and purpose of visit. The POC must digitally sign the form using a PIN before submitting it via encrypted email to the security mailbox. The document explicitly states that uncleared visitors shall only access unclassified and CUI-designated information, and personnel requiring SCIF access must provide room numbers and office codes. Authority for information collection derives from Executive Order 9397, with Social Security Numbers required for positive identification to obtain facility access authorization.

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Attachment 0006 Security Clearance Validation Sheet.pdf PDF
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C5ISR Center Visit Request V3.2.9Oct2024

Personal Information - To be completed by visitor

BUTTONS AND OTHER AREAS HAVE MOUSE OVER TIPS/DIRECTIONS

Visit Information (To be completed by visitor's sponsor (POC)- Do not include classified information on this form.)

POC - Fill out your section, then Digitally Sign before sending to the security mailbox, using Email Form button. Click the Digital Signature box above. The Sign Document window opens, click the Sign button, you will be prompted for your pin #, enter your pin, you will be prompted to save the file, choose name and location to save then EMail by.clicking the EMail Form to security button. The Email message should be Encrypted before sending to protect PII.

Arrival Date:

(mm/dd/yyyy)

Departure Date:

(mm/dd/yyyy)

This form is ONLY required for visitors with NO security clearance. Uncleared visitors shall only have access to UNCLASSIFIED and/or CUI designated information. For visitors with an active security clearance in DISS/Scattered Castles (the DoD/IC system of record), a DISS/ M3 VAR will be submitted by the visitor’s owning organization to the following SMO CODEs/PLA:

I2-Form003

Aberdeen Proving Grounds, MD W4G8AA6 (non-SCI)

W1J106 (SCI)

Plain Language Address

(PLA): SSO C5ISR

Ft. Belvoir, VA W4G8286 (non-SCI)

W1J106 (SCI)

Unclassified

Organization Country:

Middle Name:

Organization:

If Agency affiliation is classified, leave blank.

First Name:

Visitor Type:

POC Name:

Room(s) to Visit:

POC Phone:

E-Mail Address:

Site: Building/Location:

Dual Citizenship? If Yes, List Countries:

POC Org:

Time: Time:

US Citizen:

Last Name:

DATA REQUIRED BY THE PRIVACY ACT (5 U.S.C. 522a) Authority under Executive Order 9397 for the purpose of ensuring positive identification. Use of the SSN is to ensure positive identification. Routine use is to obtain authorization for your visit to these facilities and access to classified information at the host organization.Disclosure is voluntary; however,failure to provide the information may result in denial of access to host organization and access to classified information.Personnel requiring SCIF access must also provide a room number and office code for the individual or organization being visited.

Signature of Requestor (Sponsor)

Request Date:

Unclassified

Is organization affiliated with a foreign country?

Purpose of Visit:

Joint Base McGuire-Dix-Lakehurst, NJ W4G8i26 (non-SCI)

W1J106 (SCI)

txt_last_name:
txt_middle_name:
txt_email:
txt_dualCountries:
txt_visitorType_other:
txt_organization:
txt_poc_org:
txt_poc:
dd_site: [0]
dd_building: [0]
txt_arrivalTime:
txt_departureTime:
arrivalDate:
departureDate:
txt_purpose:
lbl_requestDate: 27-Nov-2024
dd_organization_country: [0]
txt_first_name:
Reset Date:
dd_visitorType: [0]
dd_dualCitizenship: [0]
dd_foreign: [0]
dd_citizenship: [0]
lbl_other: Other:
lbl_foreign: Use the C5ISR Center Foreign National Visitor Form if not a U.S. Citizen.
txt_poc_phone:
txt_rooms:
btn_submit_new:

File details come from the government source that posted it. Updated .