Site_Visit_Memorandum_Template.doc

YOUR COMPANY LETTERHEAD

Date:

MEMORANDUM FOR: 96 SFS/S-5B through AFTC/PZIOC

FROM: COMPANY’S NAME/ADDRESS

SUBJECT: Request for Badge/Pass

1. The following individuals require access to Eglin AFB to perform a site visit at Building 1219, Eglin AFB for FA2823-13-R-0002. Access will be needed for 21 October 2013 between the hours of 1300 and 1430.

2. The individuals listed have been briefed that while on the installation they must comply with all local laws and policies. The failure to comply will result in loss of base access. Each individual understands that they must go to the Security Forces Pass and Registration Office (East Gate Visitor’s Center) to receive their contractor identification badge/pass. They further understand they must have a valid drivers license/Identification card, proof of current registration and insurance while driving on the installation.

3. When first arriving to the installation the following individuals will need No escort before being allowed access to the installation

4. I understand it is the contractor’s responsibility to collect the badges of terminated employees and to collect the badges at the conclusion of the work that was to be accomplished. Further, I understand that the contractor is responsible to turn the badges/passes in to the Security Forces Pass and registration office as soon as all work is complete.

Name of Individual

Days/hrs of access SSN/Date of Birth /Drivers Licence #/State *John Q Doe Jr

Mon : 1300-1430

999-99-1111//05 May 83/1235897 (AL) *Mary T Lincoln

Mon : 1300-1430

999-99-2222/05 May 83/1234567 (FL) *George B Shaw

999-99-3333/05 May 83/1235897 (AL)

*Sally Smith

999-99-4444/05 May 83/1235897 (AL)

Contractor’s Printed Name

Contractor Signature

Date Signed

MEMORANDUM FOR: 96 SFS/S-5B

FROM: AFTC/PZIOC

The contracting office hereby verifies that the above contractor has an active contract and requires access to the base installations.

Kristina B. Brannon Contract Specialist

AFTC/PZIOC

Phone #

AFTC/PZIOC/Contracting Office Representative Signature Authority: 10 U.S.C.8013, Secretary of the Air Force

Purpose: Used by the Security Forces for issuing ID media. Some organizations may routinely keep copies of the above documentation in order to maintain control over persons authorized entry into certain areas. Accountability documents are used to insure proper control over the various forms utilized in these functions.

Routine Use: In addition to those disclosures generally permitted under 5 U.S.C. 552(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C.552a(b)(3) as follows: