Blank area clearance.doc

NAVAL STATION ENTRY CLEARANCE REQUEST NAVSTAGTMO 4650/8

(Used to obtain NAVSTA approval to bring personnel on board)

1. Entry Clearance must be processed NLT 72 hours prior to arrival. Foreign National (FN) Vetting may take up to 45 days to process.

2. All persons granted a NAVSTA Clearance must have arrived onboard GTMO within 7 days after expected arrival date. After 7 days, the Entry Clearance will be cancelled and a new Clearance Request MUST be resubmitted for approval.

3. All travelers to or from NAVSTA, other than active duty military on orders with ID card, are REQUIRED TO HAVE A VALID PASSPORT.

No Exceptions. Sponsors are required to ensure non-military visitors have passports. SIGNATURE: _____________________________

Code: ( Military Contractor Gov’t Employee ( Official visitor Dependent ( Personal Visitor

STEP 1: Complete the following information:

(Military) Branch of Service: __________

Name: SSN Passport: __________________ (See note 3 above)

Rank Last Name First Name MI Birth Date: (m/dd/yr) Citizenship: (Country) Relationship to Sponsor: Gender (M)(F)

Birth Place: (city, state) Agency or Command: Arrive GTMO on: ______________ From: (location) Via (circle one) (Tropical, Lynx, Air Sunshine, AMC, other_____________ Depart GTMO on (m/d/yr) Via (circle one) (Tropical, Lynx, Air Sunshine, AMC, other ____________ To: (location) Hair Color __ Eye Color _ _ Height_______ (Inches) Weight (lbs)

Contact Security Department Badging Office to request any changes in the departure date.

Individual will be berthed at (location). Reservation Number: _______________ ( Visitors may NOT reside in Gold Hill Towers or Contractors Camp.

( Please provide the below information if a personal visitor will reside with a base resident other than the sponsor.

( Personal visitor Host ___________________________ Host Quarters ______________________

( Host place of employment_____________________, work number____________ home number ___________

Note: See the reverse side of this form for Regulations and Restrictions.

Step 2: Complete the following Sponsor Information:

Sponsor Name: GSE-10 Russel Thomas GEO / MIG-OPS 76140 _ (Rank/Rate/Grade) (First & Last Name) (Command/Organization) (Phone Number)

I understand that I am responsible for the above named individual while in GTMO, including local support. Further, I affirm that the individual, to the best of my knowledge and belief, has not been convicted of a felony by any court within the previous seven years or convicted of any misdemeanor involving violence (to include, but not limited to sexual harassment) or theft (to include, but not limited to, fraud) within the previous three years, nor is the employee currently serving a period of probation for any offense.

date phone ________________________________ __

Sponsor Signature STEP 3 (For Contractor Only): To be completed by Contracting Agency (ROICC, FSC, Other).

I recommend (circle) APPROVAL / DISAPPROVAL of this request for clearance.

date phone

Print and Sign Name of Authorized Contracting Agency

STEP 4: To be approved by the following:

Recommendations: APPROVED DISAPPROVED. Signature/Date

Department Head or COR _________ ____________ ________________________________________

Housing/NL/HH/RR _________ ____________ ________________________________________

Security Approver _________ ____________ ________________________________________

Extended Departure Date _____________ (mm/dd/yr)

Extension Approval YES NO Signature/Date

Commanding Officer ____ ___ _ _________________________________________

Information provided is protected under the privacy Act of 1974.

Distribution: Original to sponsor Copy to Operations Department.

AUTHORITY: 10 U.S.C. 5013, OPNAVINST 5530.14C, and Executive Order 9397

PRINCIPAL PURPOSE: To maintain all aspects of proper access control; to issue badges, and replace lost badges and retrieve passes upon departure; to maintain visitor statistics; collect information to adjudicate access to facilitate, and track the entry/ exit times of personnel.

DISCLOSURE: Disclosure of this information is voluntary; however, failure to provide access to the installation may impede, delay, or prevent access to the

Installation.

Regulations and Restrictions. All personnel shall follow all rules and regulations put forth by NAVSTA. Failure to abide by such rules and regulations may result in revocation of visitation permission, and expulsion from the base. The sponsor is responsible for the conduct and behavior of the personal visitor in all aspects.

1. The sponsor will ensure visitors obtain a Visitor Identification Badge upon arrival, or the next business day and return the Visitor Identification Badge to Naval Station Air Terminal Personnel the day of departure.

2. Personnel with the intention of obtaining employment on the Naval Station are not permitted as visitors. Visitors are prohibited from seeking employment with any U.S. Government Agency or Contractor located on the base. Failure to comply will result in permanent debarment from the base.

3. Visitation shall not be used as a means to secure a regular residence on board the Naval Station. As such, each visit is limited to 30 days, and a visitor shall not return to the Naval Station within 60 days of the preceding visit.

4. Visitors under the age of 18 must be under legal custody of the sponsor, under court-ordered visitation privilege, or be accompanied by a legal guardian.

5. All visitors must be in good health. Visits by the chronically ill or persons with a history of medical problems are prohibited.

6. Visits by women beyond the 29th week of pregnancy are prohibited. Women less than six weeks postpartum and infants less than six weeks of age may be approved if considered medically sound. Written certification from a medical officer or civilian physician is required to be submitted with the Personal Visitor Request.

7. Visitors are not authorized aeromedical evacuation in DOD-owned or controlled aircraft except in extenuating circumstances. Commercial air ambulance service from CONUS is available at personal expense. Cost is approximately $13,000-19,000.

8. Visitors may be treated at the U.S. Naval Hospital, Guantanamo Bay, Cuba on a space available basis for acute illness. Cost of treatment is determined each fiscal year. Prevailing rates that must be paid by the individual for the fiscal year are based on the type of care received.

9. Sponsors shall ensure visitors arrange return transportation well in advance of their departure date so as not to exceed the approved visit timeframe. Sponsors and/or visitors who do not abide by the approved departure date may be denied future visitation privileges for up to 24 months or more at the discretion of the Commanding Officer.

10. Visitors are allowed access to Morale, Welfare and Recreation facilities subject to the rank/grade of the sponsor.

11. Visitors are allowed access and shopping privileges at Navy Exchange facilities while on board the Naval Station. However, the purpose of the visit shall not be primarily to exercise shopping privileges.

12. Individuals must be prepared to defray the cost of return travel by commercial means at any time.

13. Visitors are not permitted to transport firearms onto the Naval Station.

14. By virtue of accepting transportation to the Naval Station, individuals consent to inspection of their person and property.

15. Exceptions to regulations and guidelines contained in the instruction may be submitted for consideration, in writing, via the sponsor’s command to the Security Officer.

16. The host accepts the same responsibilities for the visitor as the sponsor and must notify the Security Department Badging Office (x4046) of any changes in the visitor lodging before and after approval.

17. Failure to provide all requested information may result in disapproval of clearance.

18. Military, Contractor and Gov’t Employee extension requests must include verifiable documentation from the sponsoring command/agency i.e. (orders, memo, letter) prior to approval.

19. Visitation may be terminated by order of the Commanding Officer at any time.

20. All Naturalized or United States citizens born outside of the United States must provide proof of citizenship.

21. Lineouts void the Entry Clearance Request.

I have read and understand the above. I agree to abide by the regulations set forth, and accept full responsibility of the visitor.

Signature of Host/Date

Signature of Sponsor/ Date

THE INFORMATION PROVIDED ON THIS FORM IS PROTECTED UNDER THE PRIVACY ACT STATEMENT OF 1974.

I am not the sponsor for the visitor listed, however I have agreed to host the visitor, and he/she will reside in my assigned quarters ONLY during his/her approved visit. I will remain on base during their visit. I will contact the Naval Station Badging Office (x4046) in the case of any changes in lodging.

Signature of host: ______________________________

NAVSTA GTMO 4650/8 Revision 10: 03/6/09