Foregin National Contractor Security Access Form.pdf
PDF 89 KB Posted
- Attached to
- Chickamauga Lock Replacement Approach Wall and Decommissioning Federal contract opportunity
- Solicitation number
- W912P525RA001
About this file
This is a Foreign National Security Form required by the Nashville District Corps of Engineers for all non-U.S. citizens and permanent residents who work on Nashville District (LRN) contracts or task orders. The form must be submitted 30 days in advance of work commencement and requires approval from the HQUSACE Foreign Disclosure Officer.
The form requires detailed personal information including full name, date of birth, citizenship, passport number (with color scan), visa information (if applicable), work description, project location, dates of access, job title, and payment method. Additional requirements include documentation of legal U.S. admission and employment/immigrant visa status. Non-U.S. citizens who have lived in the U.S. for at least three years must obtain a favorable background investigation per HSPD-12. The form includes contact information for the Nashville District Security Office, with Tracy Dorrough serving as primary contact for personnel security investigations and Jay Klinger as security specialist. This form is dated March 2024 and is associated with the Chickamauga Lock Replacement Approach Wall and Decommissioning project solicitation W912P525RA001.
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Text version
COMPANY NAME / ADDRESS / MAIN PHONE #
Nashville District Corps of Engineers Foreign National Security Form
All non-U.S. Citizens, including permanent residents who work on Nashville District (LRN) contracts or task orders must be approved by the Headquarters U.S. Army Corps of Engineers (HQUSACE) Foreign Disclosure Officer before beginning any contract/task order work. Must be submitted 30 days in advance.
NOTE: At no time will a Contractor or Subcontractor be permitted to access the site until approved by the Nashville District Security Office and the Contractor Official has been notified.
FULL Name_______________________________________________________________________ (Last, First Middle)
• If you have only initials in your name, use them and state (IO). If you have no middle name, enter “NMN”
• If you are a “Jr.,”Sr.,” “II,” etc., you must include this
Date of Birth (mm/dd/yyyy): _________________ Citizenship (Country): ______________________
Passport # (Include copy scanned in color): _____________________________________________
Visa # (Include copy scanned in color if applicable): _______________________________________
* Visa information must be included unless country of citizenship is in the Visa Waiver Program
Work to be performed: (e.g. Plumbing, electrical) ________________________________________
Corps of Engineers Location (Project Office/ Work Site) Where Work is to be performed:
From & To Dates for Requested Site Access: ____________________________________________
Expected Arrival Date: ___________________ Job Title: ___________________________________
Method of Payment (U.S. Dollars, Euros etc.): ___________________________________________
Primary Company POC Name/Phone: _________________________________________________
Primary Company POC Email Address: _______________________________________________
In addition to the information above, the Contractor shall furnish documentation to verify he/she was legally admitted into the United States and has an employment or immigrant Visa (unless in the Visa Waiver Program). This includes, individuals living and working in the United States but are not U.S.
Citizens, such as permanent residents.
In addition to the requirements above, all non-U.S. Citizens who have lived in the United States for at least three years must also have or obtain a favorable background investigation in accordance with Homeland Security Presidential Directive 12 (HSPD-12) (guidance provided separately).
Nashville District Corps of Engineers Security Office Contact Information:
*Tracy Dorrough, Security Technician, 615-73-7397 email: tracy.dorrough@usace.army.mil Jay Klinger, Security Specialist, 615-736-2185 email: jason.j.klinger@usace.army.mil
* Primary - Personnel Security Investigations
March 2024 https://travel.state.gov/content/travel/en/us-visas/tourism-visit/visa-waiver-program.html mailto:tracy.dorrough@usace.army.mil mailto:jason.j.klinger@usace.army.mil
| COMPANY NAME ADDRESS MAIN PHONE: |
| FULL Name: |
| Visa Include copy scanned in color if applicable: |
| Corps of Engineers Location Project Office Work Site Where Work is to be performed: |
| Expected Arrival Date: |
| Job Title: |
| Method of Payment US Dollars Euros etc: |
| Primary Company POC Email Address: |
| Birthday format mm/dd/yyyy: |
| Country of Citizenship: |
| Passport Number: |
| What is your job?: |
| Begining and End dates for Site Access: |
| Primary Company POC Name Phone: |
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