GSA6102-19 Visit Authorization Request (VAR) .pdf

GSA 6102 (REV. 9/2019)GENERAL SERVICES ADMINISTRATION

PASSING VISIT AUTHORIZATION LETTER/REQUEST

(The Security Branch requires 48 hours prior to visit.)

Request to pass Collateral Clearance: E-Mail gsa.securityoffice@gsa.gov or Fax to (202) 219-0572

Request to pass SCI Accesses: E-Mail securityprograms@gsa.gov or Fax to (202) 219-3254

Please complete the information below in its entirety.

Failure to complete all information may result in processing delays.

Purpose of Visit:

Clearance Level Required (if applicable):

Visiting Agency POC:

Visiting Agency Security Office:

NOTICE: The Privacy Act, 5 U.S.C. 552a, requires Federal agencies inform individuals at the time information is solicited, whether the disclosure is mandatory or voluntary, by what authority such information is solicited, and what uses will be made of the information. You are hereby advised that authority for soliciting your Social Security Number (SSN) is Executive Order 9397. Your SSN is needed to keep records accurate because other people many have the same name and birth date. Your SSN will be used to identify you precisely when it is necessary to certify that you have access as indicated above. Although disclosure of your SSN is not mandatory, your failure to do so may impede the processing of such clearance verifications and passing.

Name of Requestor:

Name of Supervisor Authorizing Action:

First Name: Last Name:

Name of Individual who need VAL/VAR passed:

E-Mail Address:

Place of Birth (POB):

Visiting Agency:

Address:

City: State: ZIP Code:

Date of Request:

GSA Organization:

Requestor's Phone Number:

Visiting Agency Phone Number:

SSN (Last 4 Digits):

Date of Birth (DOB):

To: Dates of Visit: From:

TS/SCISecret Top Secret

Supervisor's Signature:

Visiting Agency Security Office E-Mail Address or Fax Number:

Visiting Agency Security Office Phone Number:

mailto:gsa.securityoffice@gsa.gov?subject=Request%20to%20Pass%20Collateral%20Clearance mailto:securityprograms@gsa.gov?subject=Request%20to%20Pass%20SCI%20Accesses

GSA 6102 - Passing Visit Authorization Letter/Request felixepegueroluna 11.0.0.20130303.1.892433

GSA 6102 (REV. 9/2019)

GENERAL SERVICES ADMINISTRATION

PASSING VISIT AUTHORIZATION LETTER/REQUEST

(The Security Branch requires 48 hours prior to visit.)

Request to pass Collateral Clearance: E-Mail gsa.securityoffice@gsa.gov or Fax to (202) 219-0572 Request to pass SCI Accesses: E-Mail securityprograms@gsa.gov or Fax to (202) 219-3254 Please complete the information below in its entirety. Failure to complete all information may result in processing delays.

Purpose of Visit:

Clearance Level Required (if applicable):

Visiting Agency POC:

Visiting Agency Security Office:

NOTICE: The Privacy Act, 5 U.S.C. 552a, requires Federal agencies inform individuals at the time information is solicited, whether the disclosure is mandatory or voluntary, by what authority such information is solicited, and what uses will be made of the information. You are hereby advised that authority for soliciting your Social Security Number (SSN) is Executive Order 9397. Your SSN is needed to keep records accurate because other people many have the same name and birth date. Your SSN will be used to identify you precisely when it is necessary to certify that you have access as indicated above. Although disclosure of your SSN is not mandatory, your failure to do so may impede the processing of such clearance verifications and passing.

Clearance Level Required (Select one of the following): Secret, Top Secret, or TS/SCI.