O M_Attachment_H _VAR.pdf

Annex A.

(UNCLASSIFIED//FOUO)

VISITOR ACCESS FORM

Allow 2 working days for visitor processing

Visitors are restricted to US citizens who have a specific need for access for the purpose of conducting official government business or mission related activities.

Agency/ Employee Type Armed Last, First, M.I. SSN DOB (OGA, CON, FBI) (Y/N)

DATE (S) OF VISIT: _

POINT OF CONTACT:

Last First

EXT:

PURPOSE OF VISIT:

SPECIAL INSTRUCTIONS:

PHYSICAL ACCESS: □ NO SCIF □ SCIF

INFORMATION ACCESS: □ UNCLASSIFIED □ SECRET □ TOP SECRET □ SCI

□SI □TK □HCS □G

Certification and Approvals: CHECK ONE

□ I certify that the above named individual(s) require access for the purpose of conducting official government business or mission related activities.

□ I certify that the above named individual(s) require access for the purpose of a family visit/tour to see TSC artifacts. I certify that I am responsible for the conduct of my guests. SCIF access is not permitted and visits will take place between 0800-1700 only on weekdays.

SPONSOR: (PRINT AND SIGN) DATE:

UNIT CHIEF: (PRINT AND SIGN) DATE:

SECURITY OFFICER: (PRINT AND SIGN) DATE:

Clearance passed to FBI/TSC: □Yes □No Access Permitted: □Yes □No Badge Type: ( □FBI □OGA □CON □VIS □VIP) Clearance Level: □ None □ Secret

Unescorted Access □Yes □No □ Top Secret □ TS SCI

Privacy Act Statement: The collection of the requested information, which is authorized by 5 U.S.C. § 301, 44 U.S.C. § 3101, and, in the case of social security numbers, by Executive Order 13,478, is relevant and necessary to determine eligibility to access FBI facilities. Submission of this information is voluntary; however, your failure to supply all of the information requested may impede or preclude agency action regarding your access to FBI space.

This information is maintained in the FBI Central Records System, Justice/FBI-002, a description of which can be found at www.justice.gov/opcl/privacyact.html#FBI This information may be disclosed in accordance with the routine uses referenced in this notice.

(UNCLASSIFIED//FOUO)

http://www.justice.gov/opcl/privacyact.html#FBI