ITAR_Certification__Visitor_Badge_Request.doc

ITAR CERTIFICATION / VISITOR BADGE REQUEST

SECTION A (TO BE COMPLETED BY VISITOR)

U.S. MILITARY/U.S. GOVERNMENT PERSONNEL

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YES

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NO

U.S. GOV’T AFFILIATION

NAME OF COMPANY

COMPANY ADDRESS (MUST BE COMPLETE STREET ADDRESS, CITY, STATE AND ZIP CODE. P.O. BOX IS NOT ACCEPTABLE)

COMPANY TELEPHONE NUMBER

(FIRST, MIDDLE & LAST)

I hereby certify that the above employee(s) is/are U.S. persons as defined in the International Traffic in Arms Regulations (ITAR), Section 120.15 which includes U.S. citizens, or lawful permanent residents of the United States and protected individuals; and if applicable (see instructions on page 3) an employee background investigation has been completed with favorable results (no adverse information) in accordance with Supplier/Contract Labor contractual Term & Conditions. In the case of Contract Labor personnel, certify the background investigation is in process.

NAME /APPROVAL OF VISITOR COMPANY OFFICIAL CERTIFYING U.S. PERSON STATUS AND/OR BACKGROUND INVESTIGATION COMPLETION Approval OF VISITOR COMPANY OFFICIAL CERTIFYING U.S. PERSON STATUS AND/OR BACKGROUND INVESTIGATION COMPLETION (TYPE NAME)

TITLE OF VISITOR COMPANY OFFICIAL CERTIFYING U.S. PERSON STATUS AND/OR BACKGROUND INVESTIGATION COMPLETION EMAIL OF VISITOR COMPANY OFFICIAL CERTIFYING U.S. PERSON STATUS AND/OR BACKGROUND INVESTIGATION COMPLETION

DATE (MM/DD/YY)

TELEPHONE

SECTION B (TO BE COMPLETED BY NORTHROP GRUMMAN REQUESTOR)

REQUESTOR NAME

REQUESTOR/HOST EMAIL

TELEPHONE

ORG/MAILSTOP OR ZONE

MANAGER’S NAME

TELEPHONE NO.

ORG/MAIL STOP OR ZONE

BUYER (IF APPLICABLE)

TELEPHONE NO.

ORG/MAIL STOP OR ZONE

CLASSIFIED VISIT

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YES

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NO

SHIFT

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1ST

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2ND

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3RD

LENGTH OF VISIT (MONTH/DAY/YEAR)

MONTH

DAY

YEAR

FROM

TO

TYPE OF BADGE

FORMDROPDOWN

DELIVER TO: (SITE / LOBBY)

REASON FOR VISIT

CONTRACT/P.O. NUMBER

EXPIRATION DATE

SECTOR SITES TO BE VISITED

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BETHPAGE

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EL SEGUNDO

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MELBOURNE

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PALMDALE

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RANCHO BERNARDO

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ST AUGUSTINE

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HAWTHORNE

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OTHER

FREQUENCY OF VISIT

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RESIDENT (40 HRS PER WK)

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WEEKLY

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MONTHLY

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OTHER

SECTION C (TO BE COMPLETED BY CPSO/AUTHORIZED SECURITY PERSONNEL)

APPROVED

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YES

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NO

DATE (MM/DD/YY)

SIGNATURE

SECTION D (TO BE COMPLETED BY SECURITY BADGING OFFICE PERSONNEL ONLY)

APPROVED

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YES

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NO

DATE (MM/DD/YY)

SIGNATURE

INSTRUCTIONS

This form is required for all non-escort visits in excess of one business day to Northrop Grumman facilities. This includes subcontractors, vendors, suppliers, contractors, contract laborers and non-military government employees. (FOR U.S. MILITARY AND U.S. GOVERNMENT PERSONNEL, SECTION A CAN BE COMPLETED BY THE NORTHROP GRUMMAN HOST/REQUESTOR WITH THE ASSISTANCE O F THE AUTHORIZED SECURITY PERSONNEL.) Home locations of visitors to Northrop Grumman facilities must complete Section A for their employees and forward to the Northrop Grumman host/requestor five business days prior to visit.

This form must be updated any time any of the information regarding Company Name, Company Telephone or Company Address changes.

Host/requestor will submit the completed form to your Region/Site Security Department.

This form does not preclude the completion of additional forms; i.e., Visitor Authorization Letter, Property Passes, Visit Control Record, etc.

SECTION A – TO BE COMPLETED BY THE VISITOR ONLY.

FOR U.S. MILITARY AND U.S. GOVERNMENT VISITORS ONLY-NG HOST/SPONSOR

For U.S. military and U.S. government personnel Section A can be completed by the NG host/requestor with the assistance of the authorized Security personnel.

1) Driver’s License – Enter state, number and expiration date.

2) State-Issued ID Card – Enter state, number and expiration date.

3) U.S. Passport – Enter number and expiration date.

4) U.S. Military or Government ID Card – Enter number and expiration date.

1) Birth Certificate (B/C),

2) U.S. Passport (USPP),

3) Naturalization Document, DD1966 (Record of Military Processing), or a Report of Birth Abroad of a U.S. Citizen (Form FS-240).

NOTE:

Documentation acceptable for validating U.S. Person status are listed below:

1) Resident Alien Card, Form I-551

2) Permanent Resident Card, Form I-551

3) Reentry Permit, Form I-327

4) Processed for admission as an LPR, form I-94 stamped on foreign passport or attached to passport (accompanied by temporary I-551).

5) Temporary Resident Card, Form I-688.

6) Refugee Travel Document, Form I-571.

SECTION A (Continued) – TO BE COMPLETED BY THE VISITOR ONLY.

Note: Contract Labor personnel may be processed for a Long Term Badge if the background Investigation is in process:

A background investigation is not required for any visitor type that is not addressed above i.e. customer personnel, military personnel, and program partner personnel.

· Company Security Manager;

· Company Human Resource Manager;

· Company President /Owner.

NOTE: Visitor can not verify them self

SECTION B – TO BE COMPLETED BY NORTHROP GRUMMAN REQUESTOR/HOST.

SECTION B – CONTINUED

1. LONG TERM BADGE – (Photo): This is a horizontal format photo badge that is issued to personnel that have operations located within IS Facilities and require continuing unescorted access throughout the facility.

2. NO ESCORT-REQUIRED VISITOR BADGE – (Photo): This is a temporary badge that is issued to short-term visitors that allows them unescorted access within the facility.

3. ESCORT-REQUIRED VISITOR BADGE - (No Photo): A temporary badge that is issued to visitors not employed by Northrop Grumman who are visiting the Integrated Systems site on a one-time or infrequent basis that requires escort by approved escorts while on company property.

(Contract/Purchase Order number, as required.)

· Resident – On site 40 hours a week.

· Weekly – Visits site every week but less than 40 hours.

· Monthly – Visits the site periodically on a continuing and regular basis.

· Other – Occasional non-specific visit schedule. Badging will require further specific justification.

SECURITY PROCESSING

When the “Classified Visit” block is checked “Yes”, check the “Incoming Visit Access” CSIS panel to determine if a classified visit was passed and recorded, or use JPAS to determine clearance level. Once the level of clearance has been determined, annotate it in the “PCL” column.

P0-F162 (11-08)