Devens_Visitors_Pass_Request.pdf
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- Solicitation number
- W15QKN26QA132
About this file
This is a form for requesting access control visitor passes to Fort Devens Installation. The form is divided into two sections: applicant submission and installation access control office processing.
The applicant section requires collection of personal information including name, Social Security number, driver's license details, citizenship status, date of birth, and place of birth. Applicants must disclose whether they are registered sex offenders or have felony convictions. The form requests the reason for visit, with options including non-DoD contractor/vendor, foreign national, training/appointment, family care provider, drill/muster, or other purposes. Applicants must identify the building number they are visiting, provide a point of contact name and phone number, and specify the number of requested visit days (01-30 days). The form includes a prior pass history question and requires applicant certification acknowledging mandatory background screening consent, understanding that access may be revoked without reason or notice, responsibility for pass care, and obligation to report lost, damaged, or stolen passes to Fort Devens Police. All applicants must certify that provided information is true and accurate.
The issuing official section documents approval or denial decisions, pass number assignment, vetting results (renewal, NCIC hits, or NIR status), expiration date, escort requirements, and any relevant FBI or State Identification Division information. If access is denied, the form requires documentation of the category letter for denial and associated charges. The form is protected under the Privacy Act, with SSN requested pursuant to Executive Order 9397 for record accuracy purposes.
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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 .