Attachment 26 - FLETC Form 121-00-02 Visitor Access Request.pdf

DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

VISITOR ACCESS REQUEST

Privacy Act Statement:

Authority: 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 https://www.govinfo.gov/content/pkg/FR-2010-02-03/html/2010-2206.htm.

Disclosure: Disclosure of this information is voluntary. Failure to provide requested information may result in denial of access to the FLETC property.

SECTION A - To be completed by Applicant

1. Applicants Full Name:

(Last, First, Middle)

Aliases Used (nicknames, maiden names, etc):

2. Residential Address: Street Address:

City, State, Zip code:

3. Driver's License: State Driver's License #:

4. Country of Citizenship (List all that apply * ): (* If not a U.S. Citizen, you must complete the DHS Form 11055 or 11059)

5. Dual Citizen: Yes No 6. Place of Birth (City and State): 7. Date of Birth:

8. Gender: Male Female 9. Social Security #: 10. Current PIV/CAC Card: Yes No

11. Contact Information: Home or cell phone number: E-mail

12. Date Completed:

SECTION B - To be Completed by Sponsor (Must be a Federal Employee)

1. Sponsor Name: Agency:

E-mail Address: Office/Cell Number:

2. Type of access requested for Applicant: Graduation Guest Frequent Vendor One Time Vendor PO Staff 5 Day or Less Visitor 5 Day or Less Contractor Frequent Visitor Transporter/CU/FLETC REC

3. Class Number (if a Graduation Guest):

4. Relationship to Applicant (if a Visitor):

5. Company Name (if a Vendor or a 5 Day or Less CTR):

6. Requested Access Dates: Start Date: Work End Date:

SECTION C - To be Completed by FLETC Security

1. NCIC Check:

No Results Found Results Found

ARN:

FBI Number:

2. Type of Badge to be Issued::

5 Day or Less Contractor

Frequent Vendor

Frequent Visitor

5 Day or Less Visitor

Graduation Guest

One Time Vendor

PO Staff

Transporter/CU/FLETC REC

3. OSPR Decision: Approved Denied

Approved Start Date: Approved Expiration Date:

OSPR Initials: Date:

Notes:

FLETC Form 121-00-02 (4/20) Page 1 of 1 vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight vswilson Highlight

DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

VISITOR ACCESS REQUEST

Department of Homeland Security Federal Law Enforcement Training Centers BADGE application Privacy Act Statement:

Authority: 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 https://www.govinfo.gov/content/pkg/FR-2010-02-03/html/2010-2206.htm.

Disclosure: Disclosure of this information is voluntary. Failure to provide requested information may result in denial of access to the FLETC property.

SECTION A - To be completed by Applicant (Last, First, Middle)

2. Residential Address:

3. Driver's License:

(* If not a U.S. Citizen, you must complete the DHS Form 11055 or 11059)

5. Dual Citizen:

8. Gender:

10. Current PIV/CAC Card:

11. Contact Information:

SECTION B - To be Completed by Sponsor (Must be a Federal Employee)

2. Type of access requested for Applicant:

6. Requested Access Dates:

SECTION C - To be Completed by FLETC Security

1. NCIC Check:

2. Type of Badge to be Issued::

3. OSPR Decision:

FLETC Form 121-00-02 (4/20) 9.0.0.2.20120627.2.874785