Attachment 11 FLETC Form 121-00-02 Visitor Access Request.pdf

Sex: Male Female

(*Non- U.S. Citizens must complete DHS Form 11055)

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Notes:

FLETC Form 121-00-02 (4/26) Page 1 of 2

E-mail:

Agency:

Vendor

SECTION III - To be Completed by FLETC Security

NCIC Check:

FBI #:

ARN:

Office/Cell #:

State Issued:

Utility

Contractor

Access Request End Date:

Sponsor Name:

E-mail:

Type of Access Requested (see instruction page)

5 -Day or Less Pass

Social Security #:

Full Name (Last, First, Middle):

Aliases Used:

Residential Street Address:

City, State, Zip:

Driver's License #:

Place of Birth (City and State or Country):

Country of Citizenship (list all that apply):

Home/Cell #:

Results Found:

Company Name (if applicable):

Relation to Applicant (if Transporter):

Reason for Visit:

Access Request Start Date:

PO Staff

Transporter

Proximity Badge Access

Frequent Visitor

SECTION II - To be Completed by Federal Sponsor

Current PIV/CAC: No Yes Date of Birth:

DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

VISITOR & VENDOR ACCESS REQUEST

PRIVACY ACT STATEMENT

Authority to Collect This Information: 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: The purpose for collecting and maintaining this information is to allow individuals access associated with DHS/FLETC facilities and perimeter access control, as well as visitor security and management.

Routine Uses: System of Records Notice (SORN) DHS/ALL-024 located at www.govinfo.gov Disclosure: Disclosure of this information is voluntary. Failure to provide requested information may result in denial of access to the FLETC property.

SECTION I - To be Completed by Applicant

Visitor

FLETC Surge Only

Contractor -Temp (T/I)

Delivery/Pick-upFrequent Vendor

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Surge Access:

Artesia Surge Charleston Surge Glynco Surge

5-Day or Less Access:

Artesia VCC Charleston VCC Cheltenham VCC Glynco VCC

Proximity Access:

Artesia Proximity Charleston Proximity Cheltenham Proximity Glynco Proximity

Purpose This form is used to request access to Federal Law Enforcement Training Centers (FLETC) facilities for visitors, vendors, contractors, and other authorized individuals. Please read all instructions carefully before completing the form.

5-Day or Less Access

• Requirements: NCIC background check is required

• Badge Issued: Paper pass. Not to exceed 5 days

• Notes: This access is for visitors requesting access for five days or less.

• Graduation guests should submit via e-VAR or in-person. If access is requested for more than 2X in one month, the applicant will require fingerprints for Proximity access (see below)

Proximity Badge - Unescorted Access

• Requirements:

o NCIC background check is required.

o Fingerprints are required unless the applicant has an active PIV/CAC

• Badge Issued: Proximity badge

• Notes: For frequent or recurring access.

FLETC Surge Access

• Requirements:

o NCIC background check is required o May receive a temporary proximity badge for up to 45 days o Fingerprints are required if access exceeds 45 days

• Badge Issued: Determined by length of access

• Notes: For surge or temporary/intermittent construction personnel

Submitting Form

Selecting the Correct Location to Route Completed Form

Before submitting the form, use the drop-down menu to select the appropriate location based on your request:

Instructions for Completing FLETC Form 121-00-02 Visitor & Vendor Access Request

Select the option that matches your access request and location.

Additional Information

• Privacy Act Statement (see top of page 1):The information collected is used for access control and visitor management at

DHS/FLETC facilities. Disclosure is voluntary, but failure to provide required information may result in denial of access.

• Non-U.S. Citizens:Must complete DHS Form 11055 in addition to this form.

For questions or assistance, contact your Federal Sponsor or the appropriate Visitor Control Center (VCC) based on your selection.

Access Requirements

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