Attachment 11 PSNS5512-127 Visitor Badge Request.pdf
PDF 1 MB Posted
- Attached to
- Craft Portal Crane SLEP II
- Solicitation number
- N62470-20-R-1004
View the file
Other files
Show all 19
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
VISITOR BADGE REQUEST Ref: PSNS&IMFINST 5530.1
FIVE DAYS BEFORE VISIT, SPONSOR MUST FAX OR MAIL THIS COMPLETED REQUEST TO CODE 1122.2 at (360) 476-8449.
1. VISITOR'S COMMAND OR COMPANY
2. COMMAND OR COMPANY STREET ADDRESS
3. CITY
4. STATE
5. ZIP CODE
6. COUNTRY
7. PURPOSE OF VISIT
8. CONTRACT NUMBER
9. COMMAND, CODE, OR SHOP TO BE VISITED
10. VISIT START DATE
11. VISIT END DATE
12. NAMES OF PERSONNEL REQUIRING BADGES (ATTACH SEPARATE SHEET FOR ADDITIONAL NAMES.)
12a. LAST, FIRST, M.I. (M.I. REQUIRED) 12b. COMPLETE SOCIAL
SECURITY NUMBER
12c. U.S. CITIZEN
VISITORS ON NON-CLASSIFIED VISITS
MUST BRING PROOF OF CITIZENSHIP
YES NO
13. VISIT TO: PSNS & IMF
CIA
PSNS & IMF
NON-CIA
NAVBASE
KITSAP
FLC PUGET
SOUND
CREDENTIAL REQUIRED
13a. NAVBASE KITSAP CARD
13b. NAVBASE KITSAP WHITE BADGE
13c. PSNS & IMF WHITE “ESCORT
REQUIRED” BADGE
13d. PSNS & IMF RED BADGE
(ACCESS TO NNPI/RD)
13e. PSNS & IMF YELLOW BADGE
(ACCESS TO UNCLASSIFIED NNPI AND CNIA)
13f. PSNS & IMF GREEN BADGE
(ACCESS TO UNCLASSIFIED AREAS)
14. SPONSOR’S SIGNATURE 15. SPONSOR’S NAME (PRINTED)
16. BADGE NUMBER 17. CODE, SHOP, OR SHIP
18. PHONE
RED BADGE APPROVAL (FOR CODE 1122.2 USE ONLY)
DATE
PRIVACY ACT STATEMENT
AUTHORITY: Section 301 of title 5, United States Code, authorizes collection of this information. Executive Order 9397 (as amended) authorizes use of the Social
Security number to distinguish you from people with similar names. PRINCIPLE PURPOSE: The primary use of this form is by the security office to collect information to adjudicate access to PSNS & IMF and maintain visit statistics. ROUTINE USES: Information is used by the Security Office to determine basis for badging. DISCLOSURE: Furnishing your Social Security number, as well as other data, is voluntary but failure to do so may result in Visitor Control denying access to Naval Base Kitsap; Fleet Logistics Center, Puget Sound; or PSNS & IMF; or a combination of these.
PSNS&IMF 5512/127 (Rev. 5-2017) PREVIOUS EDITION MAY BE USED.
| 1 VISITORS COMMAND OR COMPANY: |
| 2 COMMAND OR COMPANY STREET ADDRESS: |
| 3 CITY: |
| 4 STATE: |
| 5 ZIP CODE: |
| 6 COUNTRY: |
| 7 PURPOSE OF VISIT: |
| 8 CONTRACT NUMBER: |
| 9 COMMAND CODE OR SHOP TO BE VISITED: |
| 10 VISIT START DATE: |
| 11 VISIT END DATE: |
| PSNS IMF: Off |
| PSNS IMF_2: Off |
| NAVBASE: Off |
| FLC PUGET: Off |
| NAVBASE KITSAP CARD: Off |
| NAVBASE KITSAP WHITE BADGE: Off |
| PSNS IMF WHITE ESCORT: Off |
| PSNS IMF RED BADGE: Off |
| PSNS IMF YELLOW BADGE: Off |
| PSNS IMF GREEN BADGE: Off |
| 15 SPONSORS NAME PRINTED: |
| 16 BADGE NUMBER: |
| 17 CODE SHOP OR SHIP: |
| 18 PHONE: |
| Fill Out: You can fill out this form on-line. |
| Print: |
| Clear: |
| 12a LAST FIRST MI MI REQUIRED: |
| 12b COMPLETE SOCIAL SECURITY NUMBER: |
| 12c US CITIZEN: Off |
| 12a1 LAST FIRST MI MI REQUIRED: |
| 12b1 COMPLETE SOCIAL SECURITY NUMBER: |
| 12c1 US CITIZEN: Off |
| 12a2 LAST FIRST MI MI REQUIRED: |
| 12b2 COMPLETE SOCIAL SECURITY NUMBER: |
| 12c2 US CITIZEN: Off |
| 12a3 LAST FIRST MI MI REQUIRED: |
| 12b3 COMPLETE SOCIAL SECURITY NUMBER: |
| 12c3 US CITIZEN: Off |
File details come from the government source that posted it. Updated .