J-0200000-03 N. SITES ACCESS REQUEST FORM (ALF 103 Rev K).pdf

ALF 103 Rev K.

Previous Editions Obsolete Northern Sites Access Request Form

NORTHERN SITES ACCESS REQUEST FORM

To: Pass & ID Office, Building 130 Visit Start Date:______________

Visit End Date:______________

From: Shop/Code/Org:________________________________________________________________

Is this a Classified Visit? YES____ NO____ (Classified Visit: Submit a request through JPAS to SMO code 630386 for NSA Cutler or SMO code N61132 for NSA Prospect

Harbor)

Company or Organization Name:________________________________________________________

Location of Visit: NSA Cutler NSA Prospect Harbor

Purpose of Visit: _____________________________________________________________________

VISITOR(S) INFORMATION: (Additional page is authorized for multiple visitors)

NAME: Last, First, Middle Initial Driver's Licence Number / State Social Security Number Date of Birth

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Camera Permit: Yes______ No______ Laptop/PDA Permit: Yes_____ No_____

Escort Required: Yes______ No______

----------------------------------------------------------Government Sponsor Use Only-----------------------------------------------------

Sponsor (POC): (printed name)_________________________________ Phone:_________________

Signature (POC):______________________________________ Date:_______________

Email:_________________________________________

PRIVACY ACT STATEMENT: Title 5 USC §301 authorizes collection of the information contained in this form. The primary use of this information is to adjudicate access to NSA Cutler and NSA Prospect Harbor, its facilities and to maintain visit statistics. The Blanket Routine

Uses that appear at the beginning of the Navy’s compilation of systems of records notices applies to this form. Executive Order 9397 (22 Nov

1943) as amended by Executive Order 13478 (18 Nov 2008), authorizes use of the Social Security Number (SSN#) to distinguish individuals.

Further, Department of Defense Instruction 1000.30 (12 Apr 2012) is also applicable. Furnishing your SSN#, as well as other data, is strictly voluntary. However, failure to do so may result in denial of your request.

Special Requirements (Check as appropriate): Questions? Contact your Installation Visit Sponsor

ALF 103 Rev J.

Previous Editions Obsolete Northern Sites Access Request Form

NORTHERN SITES ACCESS REQUEST FORM

VISITOR(S) INFORMATION: (Additional page is authorized for multiple visitors)

NAME: Last, First, Middle Initial Driver's Licence Number / State Social Security Number Date of Birth

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Days authorized on Station: Mo____/Tu____/Wed____/Th____/Fr___/Sa____/Su____ Working Hours: _____________

Signature (POC):_________________________________Date:____________________