A4_RRS_Form_31.pdf

REQUEST FOR VISIT AUTHORIZATION TO ROME RESEARCH SITE

1. Date:

2. Name of Company or Organization (complete name):

To: AFRL/RIOF Bldg. 3, West Wing, 525 Brooks Rd.

Rome, NY 13441-4503 Phone: (315) 330-2916 (DSN: 587) FAX: (315) 330-3378

4. Office Symbol (if gov’t): 5. Type of Visit (check one): Classified Unclassified

6. Street Address: 7. City, State: 8. Zip Code:

9. Name(s) of Visitor(s): SSN: Date of Birth: Place of Birth: Country of Citizenship:

Date Naturalized:

Naturalization No:

If Not a Citizen, Permanent Alien Resident No./ Expeiration Date:

Clearance Level:

Date Granted:

NOTE: To include more people on one visit request, use the space provided below.

10. Purpose of Visit:

11. Date or Period in which the Visit is Valid: (Not to exceed 1 Year)

12. Point of Contact at Rome Research Site to be Visited: (Please include name, phone and office symbol).

This is not the Security Office.

13. Point of Contact at your organization:

(Please include name and phone)

14. FOR CLASSIFIED VISIT: (Certification is made here that the above named individual(s) have a Security Clearance with type and date provided under Item 9.)

15. FOR UNCLASSIFIED VISIT: (Certification is made here that the above named individual(s) citizenship has been verified and information provided under item 9.)

Signature of Facility Security Officer or Security Manager (ONLY):

X

Signature of Facility Security Officer, Security Manager or Human Resources Officer:

X

When completed and certifications are made in either Item 14 or 15, fax this form to:

AFRL/RIOF Fax# (315) 330-3378 or DSN: 587-3378

Mailing Address: AFRL/RIOF Bldg. 3, West Wing, 525 Brooks Rd.

Rome NY 13441-4503 To confirm receipt of this visit request please dial (315) 330-2916

NOTE: All visitors will need to show a picture ID (driver’s license, military or government ID).

Personnel without a security clearance verified in advance will not be admitted into any classified areas or discussions. All visitors are required to be citizens of the United States. No exceptions will be made to waive the requirements for a security ckearance for classified visits. Hand carrying of a Security Clearance is not permitted.

Please let us know when the visit authorization for a group or an individual is no longer required, as we are obligated to cancel outstanding visit requests.

RRS FORM 31, MAY 2010 Prescribing Directive RRSI 31-402

9. Name(s) of Visitor(s): SSN: Date of Birth: Place of Birth: Country of Citizenship:

Date Naturalized:

Naturalization No:

If Not a Citizen, Permanent Alien Resident No./ Expeiration Date:

Clearance Level:

Date Granted:

Item 9 Continued: ADDITIONAL VISITOR INFORMATION

Rev. 02/08