FLETC Form 121-00-02 VAR.pdf

DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

VISITOR & VENDOR ACCESS REQUEST

Privacy Act Statement:

Authority: 5 U.S.C. 301; the Homeland Security Act, codified in Title 6 of the U.S. Code; 44 U.S.C. 3101; and Executive Order (EO) 9397; EO 12968; and Federal Property Regulations, issued July 2002.

Purpose: The purpose for collecting and maintaining this information is to allow individuals access associated with DHS/FLETC facilities and perimeter access control, as well as visitor security and management.

Routine Uses: System of Records Notice (SORN) DHS/ALL-024 located at https://www.govinfo.gov/content/pkg/FR-2010-02-03/html/2010-2206.htm.

Disclosure: Disclosure of this information is voluntary. Failure to provide requested information may result in denial of access to the FLETC property.

SECTION A - To be completed by Applicant

1. Applicants Full Name:

(Last, First, Middle)

Aliases Used (nicknames, maiden names, etc):

2. Residential Address: Street Address:

City, State, Zip code:

3. Driver's License: State: Driver's License #: 4. Date of Birth:

5. Place of Birth (City and State or Country): 6. Dual Citizen of another Country?: Yes No

7. Country of Citizenship (List all that apply * ): (* If not a U.S. Citizen, you must complete the DHS Form 11055 or 11059)

8. Gender Male Female 9. Social Security #: 10. Current PIV/CAC Card: Yes No

11. Contact Information: Home or cell phone number: E-mail:

12. Last Date on FLETC: 13. Date Completed:

SECTION B - To be Completed by Sponsor (Must be a Federal Employee)

1. Sponsor Name: Agency:

E-mail Address: Office/Cell Number:

2. Type of access requested for Applicant: Graduation Guest One Time Vendor Frequent Vendor Transporter One Time Visitor 5 Day or Less Contractor

3. Class Number (if a Graduation Guest):

4. Relationship to Applicant (if a Visitor):

5. Company Name (if a Vendor or a 5 Day or Less CTR):

6. Requested Access Dates: Start Date: End Date:

SECTION C - Type of Access (To be Completed by FLETC Security)

1. Type of Access:

NCIC Only-Paper Pass: Fingerprints Required - Prox Badge: No NCIC - Prox Badge: NCIC Only-Prox Badge:

5 day or less contractor PO Staff

One Time Visitor PO Staff (If no PIV/CAC)

Frequent Vendor

Transporter

One Time Vendor

Graduation Guest

2. NCIC Check:

No Results Found Results Found

ARN:

FBI Number:

Notes:

FLETC Form 121-00-02 (7/23) Page 1 of 1

Frequent Visitor PO Staff

Frequent Visitor http://www.govinfo.gov/content/pkg/FR-2010-02-03/html/2010-2206.htm DSimmons Underline

Instruction Page

Limited access to FLETC facilities involves duties and responsibilities of limited relation to the agency or program mission. Personnel with limited access includes visitors, vendors, construction workers, utilities workers, pesticide control workers, etc. The types of personnel vetting conducted on these personnel are as follows:

NCIC Check and Fingerprint Check (SAC)

1. Frequent vendors with access to make deliveries (Coca-Cola, food deliveries, newspaper, FedEx, UPS, etc...)

2. Pest control personnel with no building access

3. Groundskeepers

Proximity card – Limited to the hours of 0600-1800

Access for after hours, weekends, holidays must be requested in advance

4. Transporters NCIC Check Only - Paper Pass

1. One Time Visitors

2. Graduation Guests

3. One Time Vendors

4. 5 day or less Contractors

Paper badge - Limited to the hours of 0600-1800

Note: Contractors, volunteers, interns, consultants, etc., providing support services to FLETC and who require unescorted access to FLETC facilities, FLETC- controlled buildings, access to FLETC sensitive information, or access to IT systems, will require a full background investigation. The investigation type will depend on the type of access required.

NCIC Check Only - Proximity Card

1. Frequent Visitor

2. PO Staff (If no PIV/CAC)