Attachment VI - Visitor Access Request Form.pdf

Attachment VI

Visitor Access Request (VAR) Form

Last Name: First Name: Middle Name:

Social Security Number:

Email address:

Date of Birth:

Contractor/Vendor Name:

Back Ground Check Type* Agency Date Disposition

Clearance Level (If required for the position):

Contract Number: Order Number (if applicable):

Facility to be visited:

COR:

Contractor Program Manager:

I certify that to the best of my knowledge and belief all of the information on this form is correct. I also understand that failure to provide complete and accurate information may result in administrative, criminal, or civil penalties.

Name/ Date

Facility Security Officer (FSO) Company

DUNS:

CAGE:

Attachments: Declaration for Federal Employment (OF-306), and Contractor Employee’s Resume.

* The following investigations meet or exceed requirements for CAC issuance - provided the contractor employee does not have a break in federal service of 24 months or more:

Single Scope Background Investigation (SSBI) Single Scope Background Investigation – Periodic Reinvestigation (SSBI-PR) Phased Periodic Reinvestigation PPR (equivalent to an SSBI-PR) Access NACI (ANACI) National Agency Check with Local Agency and Credit Checks (NACLC) Periodic Reinvestigation- Secret (PRS) Periodic Reinvestigation (PRI) Minimum Background investigation (MBI) Limited Background Investigation (LBI) Background Investigation (BI) Child Care NACI (CNACI) National Agency Check with Written Inquiries (NACI)

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 133 and E.O. 9397

PRINCIPAL PURPOSE(S): Collection of social security numbers and other personal identifiers is used to ensure positive identification of individuals in order to successfully register them as CVS users.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use as follows: The "Blanket Routine Uses" set forth at the beginning of OSD's compilation of systems of records notices apply to this system. The Federal, State agencies and private entities, as necessary, on matters relating to securing information during the conduct of official business, utilization review, professional quality assurance, program integrity, civil and criminal litigation, and access to Federal government facilities, computer systems networks, and controlled areas.

DISCLOSURE: Voluntary; however, failure to provide this information will result in failure to register an individual as a CVS user.