Devens_Visitors_Pass_Request.pdf
PDF 527 KB Posted
- Attached to
- Full Window Replacement, Building 674, U. S. Army Garrison Devens Reserve Forces Training Area (RFTA)
- Solicitation number
- W15QKN26RA056
About this file
This is a Request for Fort Devens Access Control Visitors Pass form, a template used by the Fort Devens military installation to process visitor access applications.
The form requires applicants to provide personal identification information including name, Social Security Number, driver's license details, and citizenship status, along with declarations regarding sex offender registration and felony convictions. Applicants must specify their reason for visit, selecting from categories such as Non-DoD Contractor/Vendor, Foreign National, Training/Appointment, Family Care Provider, or Drill/Muster, and indicate the requested duration (01-30 days). The application requires identification of the specific building being visited and the point of contact with their phone number. Section 4 contains five certification statements requiring applicant acknowledgment of mandatory background screening consent, understanding that access may be revoked without reason or notice, responsibility for pass security, and obligation to report lost, damaged, or stolen passes to Fort Devens Police. The form certifies that all provided information is truthful and accurate. Section 5, completed by the Installation Access Control Office, documents the issuing official's approval or denial decision, vetting results (Renewal, NCIC Hit(s), or NIR status), pass number, expiration date, escort requirement, and relevant background check information including FBI and State Identification Division results. Access denial decisions include a category letter and charges documentation.
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Text version
REQUEST FOR FORT DEVENS ACCESS CONTROL VISITORS PASS
SECTION BELOW IS FOR USE BY THE INSTALLATION ACCESS CONTROL OFFICE ONLY
PRIVACY ACT ADVISEMENT: The information requested is for the purpose of granting access to the Fort Devens Installation. The
SSN, required for record accuracy, is requested pursuant to EO 9397. All information that contains PII is protected as required.
1. APPLICANT INFORMATION:
Last Name: ______________________First Name: ________________________ Middle Name: _____________________
SSN: _______________________________ Driver’s License #:_________________________________ DL State:_____
Are you a Registered Sex Offender? Yes No Any felony convictions? Yes No Are you a U.S. Citizen? Yes No
Place of Birth (City/State or Country):_______________ Date of Birth (MM/DD/YY): ____________Gender: M___ F
2. REASON FOR VISIT: ______ Non-DoD Contractor/Vendor _____ Foreign National _____ Training / Appointment
______ Family Care Provider _____ Drill / Muster _____ Other ________________________
Have you received a Visitor Pass from Fort Devens within the past year? Yes ____ No____
How many days are you requesting? (01-30 days): _______________________
3. BUILDING NUMBER VISITING: _________________ POC NAME:__________________POC PHONE #:_______________
POCKDKDKD
4. APPLICANT CERTIFICATION:
1. I understand that I must give Fort Devens Police consent to an initial and periodic background screenings prior to and after the issuance of an installation access pass. Failure to do so will result in the termination of the application process.
I further understand that these background screenings will determine my eligibility for access and continued access during the term of my requested visit.
2. I understand that my access may be revoked at anytime without reason or notice.
3. I understand that I must properly care for my pass to prevent damage, or unnecessary wear, loss or theft.
4. I understand that I must immediately report any lost, damage or stolen pass to the Fort Devens Police.
5. All the information provided above is true and accurate and I have read all my responsibilities as an applicant for access to Fort Devens and its surrounding facilities.
(Applicant’s Printed Name) (Signature) (Date)
5. ISSUING OFFICIAL: APPROVED / ACCESS DENIED
Pass #:_______________________________
Vetting results: Renewal ____ NCIC Hit(s) ____ NIR ____ Expiration Date: _______________________ Escort Required: Yes____ No____
FBI:______________________ Category Letter for Access Denial:_________ SID:______________________ Charge(s): _________________________________________________________ SID: ______________________ _________________________________________________________
(Issuing Official’s Printed Name) (Signature) (Date)
File details come from the government source that posted it. Updated .