JL-5-NBG_Base Access Request - Blank Form.pdf

Date:

To: Naval Base Guam (NBG) Visitor Control Center From: NAVFAC Marianas, Facilities Engineering & Acquisition Division, PWD (NBG)

Subj: BASE ACCESS REQUEST –

CONTRACT INFORMATION

Contract No. & Title:

Contract Start & Expiration Dates:

Prime Contractor Name:

Prime Contract Address:

Contractor Coordinator:

(Name, Title & Phone Number)

Project Location(s) on Naval Base Guam (NBG) Installation(s):

(Check all that apply.)

Main Base Apra View Housing Apra Palms Housing

NAVMAG Polaris Point Turner Housing

Flag Circle JRM Naval Hospital

NCTS Other (Specify):

Required Access Dates:

(Applies only when dates differ from the contract dates stated above.)

From: To:

Required Access Days & Times:

(e.g. MON – FRI / 0600 – 1800)

EMPLOYEE INFORMATION

Attach this form with completed SECNAV forms for all employees and other required documentation for all individuals requiring base access under this contract.

SPONSOR INFORMATION

Name & Title:

Command: NAVFAC Marianas

Phone Number:

Email Address:

The above listed Prime Contractor is authorized to operate on-board Naval Base Guam Installation. The above listed Prime Contractor Coordinator will provide and liaison directly with NBG Visitor Control Center, all required contractor employee information, to include sub-contractor employee information, for the purpose of securing authorized base access credentials.

Government Sponsor Signature:

EPueblo Typewritten Text

EPueblo

DATE:

CONTRACT NUMBER & TITLE:

Name & Address of Sub-Contractor: (If applicable)

Full Legal Name (Last, First, MI) NCAC Holder

CERTIFICATION:

"I hereby certify that all personnel listed above are either born U.S. citizens, naturalized U.S. citizens with the naturalization number shown, or legal aliens with the alien registration number indicated and declare under penalty and perjury that all of the information provided on this form is true, complete and correct”.

Contractor POC Printed Name & Title Date

GOVERNMENT SPONSOR ACKNOWLEDGEMENT

Printed Name & Title Date

Typewritten Text

Untitled