Security_-_NAWS_CHINA_LAKE_-_Badge_Request_Form_5530_1_(Rev_12-17)_(003).pdf

PDF 120 KB Posted Sep 6, 2019

Attached to: N0024219RC022F1 UPS Battery Replacement
Solicitation number: N0024419Q0289
Issued by: Department of the Navy Naval Supply Systems Command

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Security_-_Master_Pass_ID_Upload_-__SSNs_Removed.xlsx	XLSX spreadsheet	Sep 6, 2019

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Arrival Date End Date:

State:

Exp Dtd Color: # of Doors:

(X) No Escort Required

(E) Escort Req'd

Sponsor's Initials

Supervisor's Initials

N3AT ISO

APPROVING OFFICIAL

NAME /SIGNATURE

C - CLPL

R - Remote North/SouthTest Range

NAWSCL

Access Badge

INSTRUCTIONS: Complete all visitor, clearance, vehicle, area access blocks where applicable.

Sponsors are responsible for obtaining the appropriate approvals for restricted area access.

TYPE ID NUMBER

Insurance Company Policy #: Model:

Name of Applicant (Last, First MI) Work / Contact Phone:

SSN (Complete) Date of Birth: Citizenship (If not USA Provide Passport or Permanent Residency card ):

Birth State / Country

Badge type: ESCORT REQUIRED UNESCORTED

Access Badge Community

S - ECRD South Test Range 5.2 Per Designation Memo

Other approved credential:

N3AT,4.7 Per Memo

F - Flight Line N3AT, N46NS, 450000D, N3/N32,410000D/E, VX-9, &

VX-31

M - Michelson / McLean / Lauritsen N3AT/NAVAIR

Sponsor's Name ( Print and Sign):

PURPOSE OF VISIT:

NAWS Badge / DoD ID

FN Official Visitor

EXPIRATION

Vehicle Identification:

FN Badge (NAVAIR 7.4 approval)

Phone #:

Applicant's Signature:

V - Vouching Privileges

In-Vehicle (Approval Required) Castle- X (Enrollment form Required)PPV Housing

DBIDS

P - Photography Privileges

5.2 Per Designation Memo

DoD Dependent Community

Clearance Level: SMO Verification (Print/Sign/Phone)

Registered Owner: License #:

Foreign National Approval N3AT, 741000D/E

AREAS APPROVING CODE

N - North Restricted Areas N3AT/NAVAIR

Job Title

Privacy Act Statement AUTHORITY: 10 U.S.C.. 5013; 10 U.S.C.. 5041; OPNAVINST 5530.14D, Navy Physical Security; EQ 9397 PRINCIPAL PURPOSE: To maintain all aspects of proper access control; to issue badges, replace lost badges, and retrieve badges upon separation; to maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/exit times of personnel.

ROUTINE USES: Information can be furnished to Federal, State, or local agencies, foreign governments, and designated contractors.

DISCLOSURE: Voluntary; however refusal to furnish requested information will result in disapproval of requested access application.

Employer: Code:

CAC #:

Security Approval Name/Signature:

Date:

Applicant acknowledges they have read and will comply with the 'Statement of Agreement' on the back of the application. Name ( Print and Sign). If processed by sponsor, the sponsor is responsible for ensuring the visitor understands the "STATEMENT OF AGREEMENT".

Official Privileges require authorized signature

FN Community:

(Approval Required)

Ombudsman:

(Approval Required)

Controlled Area Access (Authorized Signature/digital signature is required for areas being sponsored.)

NAWS 5530/1 (Rev. 12-2017)

I understand solicitation is not authorized. I further understand that photography is not authorized anywhere other than community areas on the Installation unless otherwise approved.

Search Authority (Internal Security Act of 1950, 50 USC & 797) I understand entrance into NAWSCL constitutes a consent to search and Implied Consent Policy (consent to a chemical test of blood, breath or urine for the purpose of determining alcohol/drug content).

I certify that the personal data above is true and correct.

I am responsible for the security of the badge and will not leave it unsecured at any time. I will use the badge only for the purpose issued and I will not loan the badge to any other person or use it to bring unauthorized persons onto NAWSCL. I understand that it is a security violation to photograph any NAWSCL badge. I have read and I understand the Security Warning and the Privacy Act Statement on this form.

I will immediately report the loss or theft of the badge to NAWSCL Visitor Center during normal business hours. When no longer needed, I will return the badge to the Visitor's Center, at Bldg. 01487. I will surrender the badge to authorized security personnel upon request.

Community/Temporary badges are normally authorized from 0600 to 2200 hours for access to Main Site, but may change at any time.

Statement of Agreement

I agree to the following terms for the control and use of the Naval Air Weapons Station, China Lake (NAWSCL) badge issued to me:

Table 1

NAWSCL Access Badge:

INSTRUCTIONS Complete all visitor clearance vehicle area access blocks where applicable Sponsors are responsible for obtaining the appropriate approvals for restricted area access:

Name of Applicant Last First MI:

Arrival DateWork Contact Phone:

End DateWork Contact Phone:

SSN Complete:

Date of Birth:

Citizenship If not USA Provide Passport or Permanent Residency card:

Birth State Country:

Employer:

Job Title:

Code:

Clearance LevelRow1:

SMO Verification PrintSignPhoneRow1:

CAC Row1:

TYPEOther approved credential:

ID NUMBEROther approved credential:

EXPIRATIONRow1:

State:

Registered OwnerRow1:

License Row1:

StateRow1:

Vehicle IdentificationRow2:

Insurance CompanyRow1:

Policy Row1:

Exp DtdRow1:

ModelRow1:

ColorRow1:

of DoorsRow1:

Badge type ESCORT REQUIRED UNESCORTEDRow1:

Access Badge:

Community:

Badge type ESCORT REQUIRED UNESCORTEDRow2:

DBIDS:

Badge type ESCORT REQUIRED UNESCORTEDRow3:

PPV Housing:

Badge type ESCORT REQUIRED UNESCORTEDRow2_2:

FN Official Visitor:

Badge type ESCORT REQUIRED UNESCORTEDRow4:

DoD Dependent Community:

Ombudsman Approval Required:

PURPOSE OF VISIT:

X No Escort RequiredRow1:

E Escort ReqdRow1:

AREASRow1:

Foreign National Approval:

APPROVING OFFICIAL NAME SIGNATUREN3AT 741000DE:

Sponsors InitialsN3AT 741000DE:

X No Escort RequiredRow2:

E Escort ReqdRow2:

C CLPL:

APPROVING OFFICIAL NAME SIGNATUREN3AT47 Per Memo:

Sponsors InitialsN3AT47 Per Memo:

X No Escort RequiredRow3:

E Escort ReqdRow3:

F Flight Line:

APPROVING OFFICIAL NAME SIGNATUREN3AT N46NS 450000D N3N32410000DE VX9 VX31:

Sponsors InitialsN3AT N46NS 450000D N3N32410000DE VX9 VX31:

X No Escort RequiredRow4:

E Escort ReqdRow4:

APPROVING OFFICIAL NAME SIGNATUREN3ATNAVAIR:

Sponsors InitialsN3ATNAVAIR:

X No Escort RequiredRow5:

E Escort ReqdRow5:

N North Restricted Areas:

APPROVING OFFICIAL NAME SIGNATUREN3ATNAVAIR_2:

Sponsors InitialsN3ATNAVAIR_2:

X No Escort RequiredRow6:

E Escort ReqdRow6:

R Remote NorthSouthTest Range:

APPROVING OFFICIAL NAME SIGNATURE52 Per Designation Memo:

Sponsors Initials52 Per Designation Memo:

X No Escort RequiredRow7:

E Escort ReqdRow7:

S ECRD South Test Range:

APPROVING OFFICIAL NAME SIGNATURE52 Per Designation Memo_2:

Sponsors Initials52 Per Designation Memo_2:

Official Privileges require authorized signatureRow1:

P Photography Privileges:

N3AT ISO:

Supervisor s InitialsN3AT ISO:

Official Privileges require authorized signatureRow2:

V Vouching Privileges:

N3AT ISO_2:

Supervisor s InitialsN3AT ISO_2:

Sponsor s Name Print and SignRow1:

NAWS Badge DoD IDRow1:

Phone Row1:

Applicant acknowledges they have read and will comply with the Statement of Agreement on the back of the application Name Print and Sign If processed by sponsor the sponsor is responsible for ensuring the visitor understands the STATEMENT OF AGREEMENT:

Applicants Signature:

Search Authority Internal Security Act of 1950 50 USC 797 I understand entrance into NAWSCL constitutes a consent to search and Implied Consent Policy consent to a chemical test of blood breath or urine for the purpose of determining alcoholdrug content:

I understand solicitation is not authorized I further understand that photography is not authorized anywhere other than community areas on the Installation unless otherwise approved:

CommunityTemporary badges are normally authorized from 0600 to 2200 hours for access to Main Site but may change at any time:

I certify that the personal data above is true and correct:

Check Box1: Off

Check Box2: Off

Phone:

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