Attachment 3 - Visitor Request Form.pdf

FOR OFFICIAL USE ONLY

FOR OFFICIAL USE ONLY

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 USC Section 301; Title 5 USC Section 2951; E.O. 9397 dated November 22, 1943 (SSN).

PRINCIPAL PURPOSE: To provide commanders and law enforcement officials with means by which information may be accurately identified.

ROUTINE USES: Your social security number is used as an additional/alternate means of identification to facilitate filing and retrieval.

DISCLOSURE: Disclosure of your social security number is voluntary, however, failure to provide the information requested may delay or prevent approval of your request.

NAME: AKA:

SSN: GRADE/RANK:

ORGANIZATION:

HOME ADDRESS:

PURPOSE OF VISIT:

AREA(S) TO BE VISITED:

DATE/TIME OF ARRIVAL: DATE/TIME OF DEPARTURE:

DRIVERS LICENSE #: STATE:

DATE OF BIRTH: PLACE OF BIRTH:

CITIZENSHIP: SEX:

EYE COLOR: HAIR COLOR:

WEIGHT: HEIGHT:

WORK PHONE NUMBER: HOME PHONE NUMBER:

POC AT SIERRA: POC PHONE:

CAMERA REQUIRED: YES NO

REASON CAMERA IS REQUIRED:

LE Division NCIC Check - Adverse Information – Yes No Date: Name of NCIC Operator:_____________________ Security Manager/Physical Security Specialist Approval Entry Granted – Yes No Date: Name:____________________________________

SIAD Form 1246R, 17 March 2010