PSNS Security Request Forms.pdf

Visitors to PSNS that require access to Mooring ‘A’ and Ex-CGN-9 need the following documents to establish proof of citizenship (original documents).

REQUIRED DOCUMENTS:

To be vetted with a background check and identify proofing by VCC personnel, you must bring a

REAL ID compliant valid/current government issued photo identification and current proof of citizenship. This applies to all individuals except for active-duty service members and federal civilian employees, who do not require the same background checks. Despite having a CAC, these individuals are required to bring any of the following proofs of citizenship.

▪ State issued birth certificate: This must be an original or state certified copy. Personal photocopies, electronic versions, or hospital issued birth records are NOT accepted.

▪ Enhanced state-issued driver's license only accepted from Michigan, Minnesota, New York, Vermont, and Washington.

▪ U.S. Passport (book or card): The passport can NOT be expired.

▪ Certification of Naturalization: This document (FS-550/560) must be an original; electronic or photocopies are not accepted.

▪ Born-abroad Certificate: This document (FS-240) must be an original. Electronic or photocopies are not accepted.

Additionally:

In order for PSNS sponsors to submit personnel request, all visitors are required to complete form SECNAV 5512/1 and PSNS 5512/127 with all the company’s applicable data filled in, password protect and submit via encrypted email to both michael.l.maiocco.civ@us.navy.mil and claude.d.covington.civ@us.navy.mil. These forms must be submitted two weeks prior to your visit. See forms in Enclosures 1 and 2.

Confined Space Access:

Non-government civilian contractors need to provide their own gas free certifications.

Coordinate with PSNS prior to visit.

Cell Phones:

Please leave all camera phones in your hotel room or in your car. No cameras or recording devices are authorized in the CIA at PSNS unless you have been specifically trained by PSNS

Security.

mailto:michael.l.maiocco.civ@us.navy.mil mailto:claude.d.covington.civ@us.navy.mil

Dosimetry Authorization:

The following information is required for visitor dosimetry and must be submitted on company letter head along with the access request forms, listed above, two weeks prior to arrival via encrypted email to both michael.l.maiocco.civ@us.navy.mil and claude.d.covington.civ@us.navy.mil:

• Full Name

• Social Security Number

• Sex

• Birthdate

• Employer

• Employer Address

• Employer Email

• Employer Fax Number

• Visit Dates

• Exposure Data (Quarter To Date, Year To Date, and Lifetime)

• No known medical condition preventing applicant from receiving exposure.

mailto:michael.l.maiocco.civ@us.navy.mil mailto:claude.d.covington.civ@us.navy.mil

CUI (when filled in) 0MB 0703-0061 Exp: 31 July 2027

SECNAVINST 5500.35

DEPARTMENT OF THE NAVY LOCAL POPULATION ID.CARD/BASE ACCESS PASS REGISTRATION

PRIVACY ACT STATEMENT:

AUTHORITY: 1 O U.S.C. 113, Secretary of Defense; DoD OirecUve 1000.25, DoD Personnel Identity Protection (PIP) Program; DoD lnstrucUon 5200.08, Security of DoD Installations 'and Resources and the DoD Physical Secwity Review Board (PSRB); DoD 5200.08-R, Physical Security Program; DoD Directive 5200.27, Acquisition of Information Concerning Persons and Organizations not Affiliated with the Department of Defense (Exception to policy memos); Directive-Type Memorandum (DTM) 09-012, Interim Policy Guidance for DoD Physical Access Control; DTM 14--005, DoD Identity Management Capab�ity Enterprise Services Application (IMESA) Access to FBI National Crime Information Center (NCIC) Files; and E.O. 9397 (SSN), as amended; OPNAVINST 5530.14E, Navy Physical Security and Law Enforcement Program; Marine Corps Order P5530.14, Marine Corps Physical Security Program Manual:

SORNNM05512-2 Badge and Access Control System Records and DMDC 16, Identity Management Engine for Security and Analysis (IMESA): http://dpdd.defense.gov/Privacy/ SORNslndex

PURPOSE(S): To control physical access to Department of Defense (DoD). Department of the Navy (DON) or U.S. Marine Corps Installations/Units controlled information, installations, facilities, or areas over which OoD, DON. or U.S. Marine Corps has security responsibilities by identifying or verifying an individual through the use of biometric databases and associated data processingfonformation services for deslgnaled populations fo, purposes of protecting U.S./Coalltion/allled govemmenVnatlonal security areas of responsibility and information; to issue badges, replace lost badges, and retrieve passes upon separation; lo maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/ex� times of personnel.

ROUTINE USE($): To designated contractors, Federal agencies, and foreign governments for the purpose of granting Navy officials access to their facility.

DISCLOSURE: Providing registration info_rmation is voluntary. Failure to provide requested information may result in denial of access lo benefits, privileges, and DoD Installations, facilities and buildings.

IDENTITY PROOFING AND APPLICANT INFORMATION

1. LAST NAME:

2. FIRST NAME:

5. RACE □AMERICAN INDIAN or ALASKA (Check one or more): NATIVE □ASIAN

3. MIDDLE NAME:

□ BLACK or AFRICAN AMERICAN

6. SEX □MALE

(Check one): □FEMALE,

7. DATE OF BIRTH:

8. CITY OF BIRTH:

14. NAME SUFFIX:

D Jr. D Sr. D I 0110111 0 IV

NATIVE HAWAIIAN

[JM;nE □ HISPANIC OR LA TINO □ OR OTHER PACIFIC

ISLANDER

9. STATE OF BIRTH:

10. BIRTH COUNTRY:

11. US CITIZEN (Check): □ YES □ 1 12. DUAL CITIZENSHIP: □YES ONONO CITIZENSHIP IF OTHER THAN US (Country) :

U.S. Citizen Minimum Documentation Required:

By Birth - Social Security No and/or State ID/Drivers License.

Naturalized - Certification Number, Petition Number, Date, Place and Court. United States passport number, Social Security No and/or State ID/Drivers License.

Derived - Parent's certification number, Social Security No and/or State ID/Drivers License.

Alien Minimum Documentation Required:

Registration Number, Expiration date, Date of entry, Port of entry.

13. IDENTITY SOURCE 14. DOCUMENT 15. ISSUED BY

DOCUMENTS PRESENTED: NUMBER: STATE/COURT:

O Social Security No.

0 State ID/Drivers License

0 Passport No.

□ Certification Number and Petition Number

□ Derived - Parent's Certification Number:

O Alien Registration No.

Date of Entry:

OTHER APPROVED IDENTITY SOURCE DOCUMENTS:

19. WEIGHT 20. HEIGHT 21. HAIR COLOR (Check one):

(Pounds): (Inches): □ Blond □ Brown □ Black □ Gray □

□ VVhite □ Silver □ Auburn □ Bald

23. HOME ADDRESS (Include city, state, zip code):

24, BASE SPONSOR'S NAME:

SECNAV 5512/1 (April 2025) CUI (when filled in)

16. ISSUED BY 17. ISSUED: 18. EXPIRES:

COUNTRY:

United States

United States

United States

United States

I Port of Entry:

22. EYE COLOR (Check one):

Red □ Brown 0 Green □ Blue □ Hazel

□ Black 0 Gray □ Violet D Unknown HOME PHONE (Include Area Code):

SPONSOR PHONE {Include Area Code):

g����:::�\��cv Enclosure 1 - Page 1

LOC.FEOCON

POC: Le'Ron �enee, leton.a.Ja,y;renc:e.civ@us..na,vy.mil,(703) 601·06CM ps204343 Highlight ps204343 Sticky Note Cancelled set by ps204343 ps204343 Highlight

0MB 0703-0061 Exp: 31 July 2027

SECNAVINST 5500.35

EMPLOYMENT ACTNITY INFORMATON

25. EMPLOYER NAME AND ADDRESS (Include city/state/zip code):

I EMPLOYER PHONE (Include Area Code):

26. SUPERVISOR NAME

I

SUPERVISOR PHONE/Include Area Code):

27. Check the applicable box for WORK HOURS box or check the OTHER box and enter the work hours, then check the applicable box for WORK DAYS:

WORK HOURS: □ 0600-1800 □ 0800-1700 OorHER WORKDAYS: O sN □M □ T Ow 0TH OF OsT

PRIOR FELONY CONVICTIONS

28. Have you ever been convicted of a Felony? □YES □No

Initial

REQUIREMENT TO RETURN LOCAL POPULATION ID CARD

29. I understand that I am required to return my Local Population Identification Card to the Base Pass Office when ii expires or if my employment is terminated for any reason. (initial)

AUTHORIZATION AND RELEASE AND CERTIFICATION

30. I hereby authorize the DOD/DON and other authorized Federal agencies to obtain any information required from the Federal government and/or state agencies, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense Security Service (DSS), the U.S. Department of Homeland Security (DHS).

I have been notified of DON right to perform minimal vetting and fitness determination as a condition of access to DON installation/facilities. I understand that I may request a record identifier; the source of the record and that I may obtain records from the State Law Enforcement Office as may be available to me under the law. I also understand that this information will be treated as privileged and confidential information.

I release any individual, including records custodians, any component of the U.S. Government or the individual State Criminal History Repository supplying information. from all liability for damages that may result on account of compliance. or any attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD RESULT IN FINES AND/OR IMPRISONMENT UP TO FIVE YEARS.

BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE YOU HAVE ANSWERED ALL QUESTIONS FULLY AND CORRECTLY.

I DECLARE UNDER PENAL TY OF PERJURY THAT THE STATEMENTS MADE BY ME ON THIS FORM ARE TRUE, COMPLETE AND CORRECT.

DATE SIGNATURE

FINAL DETERMINATION ON YOUR ACCESS: The Base Commanding Officer has final authority for determination on granting physical access to DON controlled installations/facilities under his/her jurisdiction.

BELOW COMPLETED BY BASE REGISTRAR PERSON CONDUCTING IDENTY PROOFING and NCIC CHECK

31. INFORMATION VERIFIED BY: 32. ENTERED IN C/S SYSTEM BY: 33. PASS ISSUE DATE: 34. PASS EXPIRATION DATE:

35. NCIC CHECK PERFORMED BY: 36. RESULTS OF NCIC CHECK: 37. RESULTS OF LOCAL RECORDS CHECK:

□NO RECORDS □RECORD IDENTIFIER □NO RECORDS □RECORD IDENTIFIER

RECORD NUMBER: RECORD NUMBER:

Office of Under Secretary of Defense Directive-Type Memorandum (DTM) 09-012, "Interim Policy Guidance for DoD Physical Access Control," December 8, 2009. DTM 09-012 requires that DoD installation government representatives query the National Crime Information Center (NCIC) and Terrorist Screening Database to vet the claimed identity and to determine the fitness of non-federal government and non-DoD-issued card holders (i.e.

visitors) who are requesting unescorted access to a DoD installation. The minimum criteria to determine the fitness of a visitor is: 1) not on a terrorist watch list; 2) not on an DoD installation debarment list; and 3) not on a FBI National Criminal Information Center (NCIC) felony wants and warrants list.

Additionally, SECNAV Memo, Policy for Sex Offender Tracking and Assignment and Access Restrictions within the Department of the Navy, of 7 Oct 08 and OPNAVINST 1752.3 established the Navy's policy on sex offenders, requiring Region Commanders (REGCOMs) and Installation Commanding Officers (COs) to prohibit sex offender access to DoN facilities and Navy owned, leased or PPV housing. This form describes the authority and purpose to collect and share the required Information; and identifies the applicanVvisitor and sponsor; and authorizes the DoD to perform the minimum vetting and fitness determination criteria. A favorable response on the vetting and fitness determination is required to receive access to DOD-controlled installation/facilities.

SECNAV 5512/1 (April 2025) CUI (when filled in) Con•okd b,: OoN CUI Category: PRVCY

LDC: FEOCON

Enclosure 1 - Page 2

POC: le'Ron lBwrence. k!ton.aJawrence.civ@us.navy.mil.(70J) 601--0604 joy.rosenblum Highlight

Controlled by: PSNS & IMF Controlled by: PSNS & IMF Security Division (Code 1120) CUI Category: PRVCY Limited Dissemination Control: FEDCON POC: James Lloyd (360) 476-8867

CUI (when filled in)

CUI (when filled in)

Ref: PSNS&IMFINST 5530.1

VISITOR ACCESS AND BADGE REQUEST

A trusted agent must submit this form 7 days before visiting Puget Sound Naval Shipyard and Intermediate Maintenance Facility (PSNS & IMF) via Microsoft Teams or encrypted e-mail to james.l.lloyd.civ@us.navy.mil, janet.r.cannes.civ@us.navy.mil, and nathan.d.ryan4.civ@us.navy.mil for PSNS & IMF Bremerton. For more information, call (360) 476-0831, (360) 476-8867, or (360) 476-5929. Refer to page 2 for detachment (DET) access instructions. For information regarding Naval Base Kitsap Pass and ID procedures, call (360) 476-4882 or (360) 476-4884.

SECTION I COMPANY OR COMAND INFORMATION

1a. COMMAND AND UNIT IDENTIFICATION CODE OR COMPANY AND CAGE CODE

b. COMMAND OR COMPANY STREET ADDRESS c. CITY d. STATE e. ZIP CODE f. COUNTRY

2a. PURPOSE OF ACCESS

b. CONTRACT NUMBER (FOR CONTRACTOR RED OR YELLOW BADGES)

e. ORGANIZATION, CODE, OR SHOP TO BE VISITED f. ACCESS START DATE g. ACCESS END DATE

SECTION II PERSONNEL REQUIRING BADGES

(ATTACH PAGE 2 FOR ADDITIONAL PERSONNEL)

3a. COMPLETE SSN b. LAST NAME c. FIRST NAME d. MIDDLE

INITIAL

e. SECURITY

CLEARANCE

(NA, C, S, or TS)

f. BADGE COLOR

REQUESTED

(see section III)

g. U.S. CITIZEN (non-classified visitors must bring proof of citizenship)

YES NO

4. VISIT TO:

CIA PSNS & IMF BUILDING (NON-CIA) DET EVERETT DET SAN DIEGO DET YOKOSUKA

Legend: NOT APPLICABLE (NA) CONFIDENTIAL (C) TOP SECRET (TS) SECRET (S) SOCIAL SECURITY NUMBER (SSN) CONTROLLED INDUSTRIAL AREA (CIA)

SECTION III CREDENTIAL REQUIRED

5a. WHITE BADGE (ESCORT AND SECURITY PLAN REQUIRED) c GREEN BADGE (GENERAL UNCLASSIFIED CIA OR DET ACCESS)

b. PSNS & IMF YELLOW BADGE (ACCESS TO UNNPI AND

CONTROLLED NUCLEAR INFORMTION AREAS. DEPARTMENT OF

DEFENSE (DoD) OR DEPARTMENT OF ENERGY (DOE) CLEARANCE

REQUIRED)

d. PSNS & IMF RED BADGE (ACCESS TO NUCLEAR WORK AREAS AND REACTOR COMPARTMENTS. DoD OR DOE CLEARANCE REQUIRED

RECIPIENT MUST HAVE ‘RESTRICTED DATA’ TRAINING )

SECTION III SPONSOR INFORMATION

6a. SPONSOR’S NAME (TENANT SECURITY MANAGER REQUIRED FOR TENANTS) b. SPONSOR’S SIGNATURE

c. BADGE NUMBER d. CODE, SHOP, OR VESSEL e. PHONE NUMBER

PSNS&IMF 5512/127 (Rev. 5-2024) (Front) PREVIOUS EDITIONS ARE OBSOLETE

Enclosure 2 - Page 1 mailto:james.l.lloyd@navy.mil mailto:janet.r.cannes@navy.mil mailto:nathan.d.ryan@navy.mil

VISITOR ACCESS AND BADGE REQUEST (CONT.)

SECTION II PERSONNEL REQUIRING BADGES (continued)

3a. COMPLETE SSN b. LAST NAME c. FIRST NAME d. MIDDLE

INITIAL

e. SECURITY

CLEARANCE

(NA, C, S, or TS)

f. BADGE COLOR

REQUESTED

(see section III)

g. U.S. CITIZEN (non-classified visitors must bring proof of citizenship)

YES NO

SECTION IV PSNS & IMF DET ACCESS

Sponsor submits this form to the site security representative if DET access is needed.

Everett: James Otterholt james.h.otterholt2.civ@us.navy.mil

San Diego: Lawrence Rosenblatt lawrence.e.rosenblatt.civ@us.navy.mil

Japan: Deogracias Pineda or Daniel Zapata deogracias.g.pineda.civ@us.navy.mil , daniel.m.zapata.civ@us.navy.mil

SECTION V ADDITIONAL GUIDANCE

1. Complete SSNs are necessary for access vetting and credential creation. DoD identification number, or other number identifiers are not a suitable alternative.

2. Sections II: indicate clearance and status. Examples include, confidential, interim secret, secret, top secret, or NA.

3. Access granted, if any, will match the level required to accomplish the purpose for access. Classified visits (red or yellow badges) also require a Defense Information Security System visit request to Security Management Organization 002515.

4. Visitors or contractors are limited to 1 year. Tenant personnel and forces afloat are eligible for 3 year access upon security manager or trusted agent submission

5. Sponsor must be a PSNS & IMF employee or PSNS & IMF approved trusted agent.

PRIVACY ACT STATEMENT

AUTHORITY: Defense Biometric Identification Data System (DBIDS) (DMDC 10 DoD): 10 U.S.C. 113, Secretary of Defense; 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; DoD Directive 1000.25, DoD Personnel Identity Protection (PIP) Program; DoD Instruction 5200.08, Security of DoD Installations and Resources and the DoD Physical Security Review Board (PSRB); DoD 5200.08-R, Physical Security Program; and E.O. 9397 (SSN), as amended. PRINCIPLE PURPOSE: The primary use of this form is by the Security Division (Code 1120) to collect information to adjudicate access to PSNS & IMF and maintain visit statistics. The records support DoD physical security programs, to issue individual facility/installation access credentials, and for identify verification purposes. The records may be accessed by other physical access control systems for further verification at other sites. Records may also be used for law enforcement purposes. ROUTINE USES: Information is used by Code 1120 to determine basis for badging. In addition to those disclosures generally permitted under 5 U.S.C. 552(a)(b), the records contained herein may be specifically disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: law enforcement routine use, Congressional inquiries disclosure routine use, disclosures required by international agreements routine use, disclosures to DOJ for litigation routine use, disclosure of information to NARA routine use, data breach remediation purposes routine use, and DoD blanket routine uses. DISCLOSURE: Furnishing your SSN, as well as other data, is voluntary, but failure to do so may result in denial of access to Naval Base Kitsap, or PSNS & IMF (or both).

PSNS&IMF 5512/127 (Rev. 5-2024) (Back)

Enclosure 2 - Page 2 mailto:james.h.otterholt2.civ@us.navy.mil mailto:lawrence.e.rosenblatt.civ@us.navy.mil mailto:deogracias.g.pineda.civ@us.navy.mil mailto:daniel.m.zapata.civ@us.navy.mil