PSNS_Visitor_CIA_Badge_Request.pdf

REQUEST FOR VISITOR BADGE Ref: NAVSHIPYDPUGETINST 5530.1

FIVE DAYS PRIOR TO VISIT, SPONSOR TO FAX OR MAIL THIS COMPLETED REQUEST TO (360) 476-5921, CODE N32222.

FAX RED AND YELLOW BADGE REQUESTS TO (360) 476-8449. FOR FISC PUGET SOUND VISITORS, FAX TO

(360) 476-6294. QUESTIONS? CALL VISITOR CONTROL AT (360) 476-4883.

1. VISITOR'S COMMAND/COMPANY

2. COMMAND/COMPANY STREET ADDRESS

3. CITY

4. STATE

5. ZIP CODE

6. COUNTRY

7. PURPOSE OF VISIT

8. CONTRACT NUMBER

9. COMMAND/CODE/SHOP TO BE VISITED

10. VISIT START DATE

11. VISIT END DATE

12. NAMES OF PERSONNEL REQUIRING BADGES: (ATTACH SEPARATE SHEET FOR ADDITIONAL NAMES.)

12a. LAST, FIRST, M.I. (M.I. REQUIRED) 12b. SOCIAL SECURITY

NUMBER

12c. U.S. CITIZEN

VISITORS ON NON-CLASSIFIED VISITS

MUST BRING PROOF OF CITIZENSHIP

YES NO

13. VISIT TO: NAVSHIPYD

PUGET CIA

NAVSHIPYD PUGET

NON-CIA

NAVSTA

BREMERTON

FISC PUGET

SOUND

CREDENTIAL REQUIRED

13a. NAVSTA BREMERTON CARD

13b. NAVSTA BREMERTON WHITE BADGE

13c. NAVSHIPYD PUGET WHITE “ESCORT

REQUIRED" BADGE

13d. NAVSHIPYD PUGET RED BADGE

(ACCESS TO NNPI/RD) (SPONSOR: FAX THIS

REQUEST TO CODE 1122.2 AT (360) 476-8449.)

13e. NAVSHIPYD PUGET YELLOW BADGE

(ACCESS TO UNCLASSIFIED NNPI & CNIA)

(SPONSOR: FAX THIS REQUEST TO CODE 1122.2 AT

(360) 476-8449.)

13f. NAVSHIPYD PUGET GREEN BADGE

(ACCESS TO UNCLASSIFIED AREAS)

14. SPONSOR'S SIGNATURE

15. SPONSOR'S NAME (PRINTED) 16. BADGE NUMBER 17. CODE/SHOP/SHIP

18. PHONE

RED BADGE APPROVAL (FOR CODE 1122.2 USE ONLY) DATE

PRIVACY ACT STATEMENT

Section 301 of title 5, United States Code, authorizes collection of this information. The primary use of this form is by the security office to collect information to adjudicate access to the Shipyard and maintain visit statistics. The Blanket Routine Uses that appear at the beginning of the Navy's compilation of systems of records notices apply to this form.

Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number to distinguish you from people with similar names. Furnishing your Social Security Number, as well as other data, is voluntary but failure to do so may result in Visitor Control denying access to Naval Station Bremerton; Fleet and Industrial Supply Center, Puget Sound; and/or Puget Sound Naval Shipyard.

PSNS 5512/127 (Rev. 7-01)