Base Access Request Form.pdf

I. Purpose of Visit Description ofthe work or visit purpose, time frame and classification level.

*Purpose of Visit:__

*Start Date: __*End Date:__ (Not to exceed 1 year)

*Will access to CLASSIFIED infonnation be required? Yes DNo D

If Yes, at what classification level? _

II. Point of Contact (POe) Data Federal civil service/military, Contracting Officer's Representative (COR), host or delegated alternate ofthe contract/visit.

Prefix: *First Name: __Middle Initial:

*LastName:

*POC Work Phone Number: __Ext.:

*POC Work Fax Number:

*POC Work E-mail Address/Signature:

III. Requestor Data The company/individual initiating this request. For example, a company's Facility Security Officer (FSO).

Is the Requestor the Facility Security Officer? Yes D NoD

*First Name:__ Middle Initial

*Last Name:

*Work Address:

*Work City:__ State:_

*Work Zip Code: __ * Work Country:__

*Work Phone Number:_/__Ext.:__

*Work Fax Number:

*Work Email Address:

IV. Company Data Contact information for official business correspondence.

*Company Name: __

*CAGE Code:__

*Is Company incorporated in US? Yes D NoD

*Is Company Foreign Owned, Controlled or Influenced (FOCI)?

YesDNoD

*Company Address: __

*Company City: __ *Company State: _

*Company Zip Code:__ *Company Country: __

*Company Phone Number: __

Company Fax Number: __

V. Contract Data All visits over 30 days require a contract number. lfworking on more than one, submit a base access request for each contract supported.

~coiii:-*Contract Number:

*Expiration Date: __

(Continued next page)

Privacy Act of 1974: This form contains identifiable personal data which is to be safeguarded pursuant to the Privacy Act of 1974. This information is to be released only to authorized personnel having a need to know for official uses. When not in use, this form is to be stored in a locked cabinet or secured room.

VI. ContractorlVisitor Data Infonnation concerning the contractor requesting base access.

*Position Title:

*Date of Birth

*SSN: (or applicable Foreign NationalID number)

Prefix: _ *First Name: __Middle Initial:

*LastName:

Nickname: Maiden Name:

*Birth City: __ *Birth State:

*Birth Country: __

*Citizenship: __

Home Email Address:

Home Phone Number:

*Home Address:__

*Home City: .~..*HomeState:_

*Home Zip Code: __*CoUlltry of Residence:__

*Please indicate your working status at this installation.

On-Site D (Employed in. a federal facility)

Off-Site 0 (Employed in. a private facility)

Visitor D (At the installation in. a visit capacity only, short term> 30 days)

Will ContractorNisitor need a picture ill/ hard badge? Yes D No D

If contractor will be working ON-SITE aboard the complex or in a federally-leased facility, complete the following:

*Work Site Location:

*Primary Building Number:__*Room Number: __

Suite Number: __* Unit Identification Code (DIC #) __

Phone # (If unknown, enter phone number ofPOC who will be able to locate the contractor.)

*Benefiting Site Location: __ Competency Code__

*TeamCode Supported: (a)__, (b) __, (c) __,

(d) __, (e) __

*Essential Personnel Status: KeyD EssentialD Non-Essential D

(Must be verified by the government POC) *After hours access? YesD No D If contractor will be supporting the installation at private contractor facility

OFF-SITE, complete the following address information:

*Company Work Address: __

*COttf{fIDty WorkCity: -----==*CompanyWotKStafe-:·=__..

*Company Work Zip Code: __*Company Work Country: __

*Company Work Phone Number: __

Company Work Fax Number: __

Work Email Address: __

If contractor is a VISITOR aboard the station, please identify the primary building(s) to be visited:

*Locations to be VisitedlBuilding Number(s): __

For form instructions and definitions, see next page.

Privacy Act of 1974: This form contains identifiable personal data which is to be safeguarded pursuant to the Privacy Act of 1974. This information is to be released only to authorized personnel having a need to know for official uses. When not in use, this form is to be stored in a locked cabinet or secured room

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Section I. Purpose of Visit

Purpose of Visit: A description of the work or visit purpose. For example: To support the F/A-18 ElF program.

Start Date: Provide the estimated date that the contractor will report to work

(mm-dd-yyyy).

End Date: Provide the date that the contractor's work/visit will expire.

Work/visit maximum is 1 year.

Will access to CLASSIFIED infonnation be required? Yes/ No IfYes, at what classification level? Indicate Confidential, Secret or Top Secret.

Section II. Point of Contact (POC) Data

The POC is the civil service or military government official sponsoring this visit.

Prefix: Mr. or Ms. First NamelMiddle InitiallLast Name: Provide first name, middle initial and last name of the point of contact (POC).

Work Phone NumberlExtJFax Number: Provide work phone and fax number of the POC and extension, if applicable.

Work Email AddresslSignature: Provide the POC's work email address. If the

POC does not have an email address or network access, this form should be signed by the POC and faxed or hand carried to the Pass Office.

Section III. Requestor Data

The company/individual initiating this request.

Is the requestor the Facility Security Officer (FSO)? Yes /No.

First NamelMiddle InitiallLast Name: Provide first name, middle initial and last name of the requestor.

Work Address: Provide work mailing address of the requestor including street address, city, state, zip and country.

Work Phone NumberlExtJFax Number: Provide work phone and fax number of the requestor and extension, if applicable.

Work Email Address: Provide the work email address of the requestor.

Section IV. Company Data

The company's official business identification for correspondence purposes.

Company Name: Provide the official company name. CAGE Code: Indicate the company's 5 digit Commercial & Government Entity (CAGE) code, if applicable. This code is used to identify a vendor by address or location for purposes of funds transfer, identification and correspondence, and is required for all contractor visit requests.

Is Company incorporated in the US? YesINo. Is Company Foreign Owned, Controlled or Influenced (FOCI)? YesINo

Company Address: Provide official company mailing address of the company, including street address, city, state, zip and country.

Company PhonelFax Number: Provide company's main phone and fax numbers.

Section V. Contract Data

.The official document outlining the requirements for base access. All visits over 30 days require a contract number. Ifworking on more than one contract, submit,a.base access request for each contract supported.

Contract Number: Provide the 13-character contract number that the contractorlvisitor will be working under or applicable agreement number.

For example: N0042196D0006.

Expiration Date: Provide the expiration date of the contract or delivery order

(mm-dd-yyyy).

(Continued on next page)

Privacy Act of 1974: This form containsidentifiable personal data which is to be safeguarded pursuant to the Privacy Act of 1974. This information is to be released only to authorized personnel having a need to know for official uses. When not in use this form is to be stored in a locked cabinet or secured room.

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Section VI. ContractorNisitor Data

Infonnation concerning the contractor requesting base access.

Position Title: Example: Management Analyst

SSN: Enter U.S. Social Security number or applicable passport, visa, alien registration or invitational travel order number.

Date of Birth: (mm-dd-yyyy)

Prefix: Mr. or Ms. First NamelMiddle InitiaIlLast Name: Provide first name, middle initial and last name ofthe contractor.

Nickname: Provide a name the contractor uses other than official name.

Birth City/State/Country: Provide city, state and country of where the contractor was born.

Citizenship: List the country of citizenship. If foreign national, contact the contractor's on-site security team or Competency 7.4.1 at 301-757-2960.

Home Email Address: Provide a home email address, if applicable.

Home Phone Number: Provide a home telephone number.

Home Address/City/State/Zip: Provide a home mailing address including

5-digit address with street, route, etc., city, state and zip code.

On-Site: Check this line if the contractor will be provided a workstation/working space aboard the complex or in a federally-leased facility.

Off-Site:-Chetktliis·lirte·iflnere-iSnoworkspace·provtde-dforthecontractoron· station.

Visitor: Check this line if the contractor is in a visit capacity and not on contract to provide services to this site.

.Will the Contractor Need a Picture IDlHard Badge? YeslNo

ON-SITE

Building Number: Provide a valid ON-SITE building number. A validation of on-site buildings will be performed upon processing of request.

Room Number: Provide ON-SITE room number.

Work Site Location: List the physical location, such as Pax, Alameda, etc., where the contractor will actually be working.

Benefiting Site Location: Provide the site which is benefiting from the contractor's support, such as working at Jacksonville for Pax River.

VIC: Provide the 5-digit unit identification code. Example: 00421.

Phone #: Provide ON-SITE phone number where the contractor will be working. If not available, list the phone number of the government POc.

Competency Code: Provide the competency code the contractor will be assigned to.

Team Code Supported: If supporting a NAVAIRlNAWCADINAS organization, provide a valid six-character team code. Provide up to 5 team codes as applicable. At least one is required. Example: 121300. To find Team

Code Listing, visit this site: ftp://otrs.navair.navy.mil/OTRSffEAM%2OCODES/.

Essential Personnel Status: Indicate whether this position is a designated key, essential or nonessential position. Contact the government POC for designation.

After hours access: Does the contractor's job require access to a government facility after normal working hours? YeslNo.

OFF·SITE

Work Address/City/State/Zip: Provide the contractor's work street address, city, state and zip code.

Workeountry:fiovidethe-contractor'-s workcountry:··

Work PhonelFax Number: Provide the contractor's work site phone and fax numbers.

Work Email Address: Provide the contractor's work email address.

VISITOR

Location(s) to be VisitedIBuilding Number(s): Indicate the building(s) the contractor will require access to during visit. A validation of on-site buildings will be performed upon processing of request.

Privacy Act of 1974: This form contains identifiable personal data which is to be safeguarded pursuant to the Privacy Act of 1974. This information is to be released only to authorized personnel having a need to know for official uses. When not in use, this form is to be stored in a locked cabinet or secured room

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