Attachment T1 - Form 21 Site Visit.xlsx
XLSX spreadsheet 28 KB Posted
- Solicitation number
- W5168W-26-R-A016
- Issued by
-
Department of the Army
About this file
This document is a Form 21 Site Visit Access Request for unescorted installation access at Fort Belvoir's Rivanna Station, associated with a Base Operations Support Services solicitation (W5168W-26-R-A016) for the Department of the Army. The form is designed to facilitate vetting and identity verification for site visit participants, with spaces to record detailed personal information for up to 32 potential visitors, including name, gender, race, date of birth, and identification details.
The site visit is sponsored by Eric Bilodeau from the DPW/OMD (Department of Public Works/Operations and Maintenance Directorate), with a contact number of 520-673-3767. The purpose of the visit is explicitly stated as a "Site Visit" related to the Base Operations Support Services contract at Rivanna Station, Virginia. The form includes privacy act statements and instructions for submission, requiring the completed document to be emailed to specific USARMY Charlottesville VA NGIC List contacts.
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Text version
Form 21
| CUI | |||
| Request for Unescorted Installation Access | |||
| For use of this form, see Army Regulation 190-13, "Installation Access" and the "Instructions" page. The proponent agency is DPTMS. | |||
| PRIVACY ACT STATEMENT | |||
| AUTHORITY: | Army Regulation 190-13, "Army Physical Security Program", 27 June 2019; Directive-Type Memorandum 09-012," Interim Policy Guidance for DoD Physical Access Control", March 19, 2013, Title 18, USC Section 1382 | ||
| PRINCIPAL PURPOSE: | To facilitate vetting, identity proofing and verification of purpose for accessing the installation as required by DTM 09-012 and the check of National Crime Information Center (NCIC) Interstate Identification Index (III) records as required by AR 190-13. | ||
| ROUTINE USES: | Information will be processed through the National Crime Information Center (NCIC) Interstate Identification Index (III) database to determine criminal history (AW AR 190-13. Personal information for individuals who are authorized to access the installation as a result of this request will be maintained on the installation access roster for the duration of the authorized access period. Personal information for individuals who are denied access to the installation as a result of this request will be maintained on the installation access roster for approximately one year after the submission of the request. | ||
| DISCLOSURE: | Disclosure is voluntary; however, failure to provide the information may result in the inability to process an individual's request for unescorted access to U.S. Army Garrison, Fort Betvoir at Rivanna Station. | ||
| EMAIL COMPLETED FORM TO: | USARMY Charlottesville VA NGIC List DL Fort Belvoir Police Leadership <usarmy.charlottesville.ngic.list.dl-fort-belvoir-police-leadersh@army.mil> and cc USARMY Charlottesville VA NGIC List PSYSEC Branch <usarmy.charlottesville.ngic.list.psysec-branch@army.mil> | ||
| THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE GOVERNMENT SPONSOR FOR THE COMPANY, ORGANIZATION,OR VISITING INDIVIDUAL: | |||
| CO or ORG*: | Dates of Access Request*: | Through* | |
| CO/ORG Point of Contact*: | Point of Contact Email Address*: | ||
| Contract #: | Point of Contact Telephone #*: | ||
| CAGE code: |
| Government Sponsor*: | Eric Bilodeau | Sponsor Telephone #*: | 520-673-3767 |
| Government Sponsor*: | Sponsor Telephone #*: | ||
| Purpose of Visit*: | Site Visit | Sponsor Organization*: | DPW/OMD |
| Full Last Name* | Full First Name* | Middle Name | Gender* | Race* | Date of Birth* | SSN#* | State License/ID, U.S. Passport or Resident Allen #* | |||
| 1 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 2 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 3 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 4 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 5 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 6 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 7 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 8 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| DPTMS (RS) Form 21 (Back) | CUI | |||||||||
| Revised 05 Feb 2014 |
| CUI | ||||||||||
| Full Last Name* | Full First Name* | Middle Name | Gender* | Race* | Date of Birth* | SSN#* | State License/ID, U.S. Passport or Resident Allen #* | |||
| 9 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 10 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 11 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 12 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 13 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 14 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 15 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 16 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 17 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 18 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 19 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 20 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 21 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| 22 | White | American Indian | ||||||||
| Black | Hispanic | |||||||||
| Asian | Pacific Islander | |||||||||
| DPTMS (RS) Form 21 (Back) | CUI | |||||||||
| Revised 05 Feb 2014 | ||||||||||
| CUI |
| 23 | White | American Indian |
| Black | Hispanic | |
| Asian | Pacific Islander | |
| 24 | White | American Indian |
| Black | Hispanic | |
| Asian | Pacific Islander | |
| 25 | White | American Indian |
| Black | Hispanic | |
| Asian | Pacific Islander | |
| 26 | White | American Indian |
| Black | Hispanic | |
| Asian | Pacific Islander | |
| 27 | White | American Indian |
| Black | Hispanic | |
| Asian | Pacific Islander | |
| 28 | White | American Indian |
| Black | Hispanic | |
| Asian | Pacific Islander | |
| 29 | White | American Indian |
| Black | Hispanic | |
| Asian | Pacific Islander | |
| 30 | White | American Indian |
| Black | Hispanic | |
| Asian | Pacific Islander | |
| 31 | White | American Indian |
| Black | Hispanic | |
| Asian | Pacific Islander | |
| 32 | White | American Indian |
| Black | Hispanic | |
| Asian | Pacific Islander | |
| CUI |
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