Attachment I - Facility Access Request Form.pdf
PDF 108 KB Posted
- Attached to
- AOC- Building Engineer Report (BER)
- Solicitation number
- 15DDHQ26R00000008
About this file
This is a Drug Enforcement Administration (DEA) Facility Access Request and Authorization form for conducting agency-specific record checks on visitors to DEA facilities.
The form is divided into two parts: Part A captures information from the access requestor (visitor), and Part B is completed by the facility employee. Part A requires the visitor to provide personal identification information including full legal name, date of birth, driver's license number and issuing state, citizenship status, Social Security number, race, and sex. The visitor must also specify the date and time of visit, the company they represent, phone number, and the purpose of the visit. Part B identifies the DEA facility employee requesting access and the personnel who will escort the visitor. The form includes an authorization statement allowing DEA investigators, special agents, or other accredited representatives to query visitor information against the Narcotics and Dangerous Drugs Information System (NADDIS), the National Crime Information Center (NCIC), and the National Law Enforcement Telecommunications System (NLETS). Access approval is valid for six months from the approval date and must be submitted to the Aviation Division Security Officer or Alternate at least 24 hours in advance of the visit. The form includes signature lines for the visitor, requesting employee, and DEA Security Officer, with checkboxes for approval or denial decisions. A Privacy Act Statement explains the legal authority for information collection under Public Law 93-479 and Executive Orders 9397, 10450, and 12356.
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Other files
| File | Type | Posted |
|---|---|---|
| A29 15DDHQ26R00000008 P00001.pdf | ||
| A28 RFQ - 15DDHQ26R00000008.pdf |
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Text version
Part A. (Access Requestor) Date of Visit
Company
Phone Number Name of Visitor
(Full Legal Name)
DOB
Driver License # State
Citizenship
SSN
Race Sex
Purpose of Visit
Signature Date at extension
Date
Date
Approved Denied
Facility Access Renewal
Requesting Employee
DRUG ENFORCEMENT ADMINISTRATION
Authorization to Conduct Agency-Specific Record Checks
*Privacy Act Protected Information*
I hereby authorize an investigator, special agent, or other duly accredited representative of the Drug EnforcementAdministration to query my Name (including Other Names Used), Social Security Number, Date of Birth, Driver's License, and State it was issued, in its Narcotics and Dangerous Drugs Information System (NADDIS), the National Crime
Information Center (NCIC), and the National Law Enforcement Telecommunications System (NLETS) indices for the purpose of unique agency-specific requirements.
Time of Visit Request Date
DEA Security Officer
Part B. (Facility Employee)
This information is required and is to be presented to the Aviation Division Security Officer or Alternate at least 24 hours in advance of the visit for processing through DEA Security. This access is good for 6 months from the approval date.
PRIVACY ACT STATEMENT
GENERAL: Pursuant to Public Law 93-479 (Privacy Act of 1974), the information is provided for employment purposes. Collection of the social security number is authorized by
Executive Order 9397 to help identify individuals because other people may have the same name. AUTHORITY: E.O. 9397; E.O. 10450; E.O. 12356; 5 U.S.C. 1303-1305; 42 U.S.C. 2165 and 2455; 22 U.S.C. 2585 and 2519; and 5 U.S.C. 3301. EFFECT: Failure to provide the necessary information could preclude your suitability for a security clearance or access to sensitive information.
For questions, please contact
The following personnel will be escorting the visitor:
Sheet1
| Request Date: |
| Date of Visit: |
| Time of Visit: |
| Company: |
| Phone Number: |
| Full Legal Name 1: |
| Full Legal Name 2: |
| Driver License: |
| State: |
| Citizenship 1: |
| Citizenship 2: |
| Citizenship 3: |
| Sex: |
| Purpose of Visit: |
| Date: |
| The following personnel will be escorting the visitor 1: |
| The following personnel will be escorting the visitor 2: |
| The following personnel will be escorting the visitor 3: |
| This information is required and is to be presented to the Aviation Division Security Officer or Alternate at least 24 hours in: |
| at extension: |
| Requesting Employee: |
| Date_2: |
| DEA Security Officer: |
| Date_3: |
| undefined: |
| Denied: |
File details come from the government source that posted it. Updated .