Attachment I - Facility Access Request Form.pdf
PDF 108 KB Posted
- Solicitation number
- 15DDHQ27R00000001
About this file
This is a Drug Enforcement Administration (DEA) Facility Access Authorization Form used to process visitor access requests to DEA facilities. The form serves as both an access request and authorization document for conducting agency-specific background record checks.
Part A of the form requires the visitor to provide personal identification information including full legal name, date of birth, driver's license number and state of issuance, 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. The visitor authorizes DEA investigators or special agents to query personal information through the Narcotics and Dangerous Drugs Information System (NADDIS), National Crime Information Center (NCIC), and National Law Enforcement Telecommunications System (NLETS). Part B requires a facility employee to submit the request at least 24 hours in advance to the Aviation Division Security Officer or Alternate for processing through DEA Security. The approved access is valid for six months from the approval date. The form includes signature and date lines for the visitor, requesting employee, and DEA Security Officer, with checkboxes for approval or denial decisions. The form also identifies personnel who will escort the visitor and provides contact information for questions. A Privacy Act Statement explains the legal authority for collection of personal information and warns that failure to provide required information could preclude security clearance or access to sensitive information.
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Other files
| File | Type | Posted |
|---|---|---|
| A28 RFQ - 15DDHQ27R00000001.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 .