Attachment_Three_-_Visit_Authorization_Request_Template.pdf

VISIT REQUEST

VISITOR CLEARANCE DATA

OPNAV 5521/27 (Rev. 1-75) S/N 0107-LF-055-2235

PRIVACY ACT STATEMENT ON PAGE 2.

CHECK ONE

REPLY REQUIRED

REPLY ONLY IF NEGATIVE(SEE CURRENT EDITION OF OPNAVINST.5510.1 FOR DETAILED INSTRUCTIONS)

FROM (COMPLETE ADDRESS OF REQUESTING ACTIVITY) DATE OF REQUEST

TO (NAME AND ADDRESS OF VISITING ACTIVITY)

SPECIFIC PERSONNEL OR SECTION

OF COMMAND TO BE VISITED

FOLD ON THIS LINE

DURATION OF VISIT (ARRIVE) (DEPART) DEGREE OF ACCESS REQUIRED

PURPOSE OF VISIT/REMARKS (IF THE VISIT IS TO A CONTRACTOR FACILITY, INCLUDE CONTRACT NUMBER IF APPROPRIATE)

NAME, RANK, TITLE OR POSITION, SOCIAL SECURITY NO. DATE AND PLACE

OF BIRTH

NATIONALITY

(CHECK ONE) LEVEL OF SECURITY CLEARANCE

U.S. CITIZEN

IMMIGRANT ALIEN

U.S. CITIZEN

IMMIGRANT ALIEN

U.S. CITIZEN

IMMIGRANT ALIEN

U.S. CITIZEN

IMMIGRANT ALIEN

U.S. CITIZEN

IMMIGRANT ALIEN

U.S. CITIZEN

IMMIGRANT ALIEN

NAME, RANK AND TITLE OF OFFICIAL AUTHORIZING VISIT AND CLEARANCE SIGNATURE

COPY TO:

Page 2 of OPNAV-5521/27 (Rev. 1-75)

PRIVACY ACT STATEMENT

AUTHORITY: E.O. 11652

PRINCIPAL PURPOSE: Information is obtained to identify personnel visiting activities when such visits are expected to involve access to classified information.

ROUTINE USE: Information provided in the form, when compared with information known to or normally in the possession of an individual, is used in determining whether or not an individual is who he purports to be when visiting an activity. The information may be disclosed to all those charged at the activity with making the foregoing determination.

DISCLOSURE: (Mandatory or voluntary; consequences, etc.): Completion of OPNAV 5521/27, including the disclosure of your Social Security Number, is voluntary. Failure on your part, however, to answer all questions, or any misrepresentation (by omission or concealment, or by misleading, false, or partial answers), may serve as a basis for denial of the request to visit, or for access to information classified in the national interest pursuant to E.O. 11652.