ATT_6_Base_Acc_Req.doc

I. Purpose of Visit Description of the 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 information be required? Yes FORMCHECKBOX No FORMCHECKBOX

If Yes, at what classification level? FORMDROPDOWN

II. Point of Contact (POC) Data Federal civil service/military, Contracting

Officer’s Representative (COR), host or delegated alternate of the contract/visit.

Prefix:

FORMDROPDOWN

*First Name: Middle Initial:

*Last Name:

*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 FORMCHECKBOX No FORMCHECKBOX

*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 FORMCHECKBOX No FORMCHECKBOX

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

Yes FORMCHECKBOX No FORMCHECKBOX

*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. If working on more than one, submit a base access request for each contract supported.

*Contract Number:

*Expiration Date:

VI. Contractor/Visitor Data Information concerning the contractor requesting base access.

*Position Title:

*Date of Birth *SSN: (or applicable Foreign National ID number)

Prefix:

FORMDROPDOWN

*First Name: Middle Initial:

*Last Name:

Nickname: Maiden Name:

*Birth City:

*Birth State:

*Birth Country:

*Citizenship:

Home Email Address:

Home Phone Number:

*Home Address:

*Home City: *Home State:

*Home Zip Code: *Country of Residence:

*Please indicate your working status at this installation.

On-Site FORMCHECKBOX (Employed in a federal facility)

Off-Site FORMCHECKBOX (Employed in a private facility)

Visitor FORMCHECKBOX (At the installation in a visit capacity only, short term > 30 days) Will Contractor/Visitor need a picture ID/ hard badge? Yes FORMCHECKBOX No FORMCHECKBOX

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

*Benefiting Site Location: Competency Code

*Team Code Supported: (a) , (b) , (c) ,

(d) , (e) *Essential Personnel Status:

Key FORMCHECKBOX Essential FORMCHECKBOX Non-Essential FORMCHECKBOX

(Must be verified by the government POC) *After hours access? Yes FORMCHECKBOX No FORMCHECKBOX

If contractor will be supporting the installation at private contractor facility OFF-SITE, complete the following address information:

*Company Work Address:

*Company Work City: *Company Work State:

*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 Visited/Building Number(s):

Section I. Purpose of Visit Purpose of Visit: A description of the work or visit purpose. For example: To support the F/A-18 E/F 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 information be required? Yes/ No If Yes, 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 Name/Middle Initial/Last Name: Provide first name, middle initial and last name of the point of contact (POC).

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

Work Email Address/Signature: Provide the POC’s work email address.

Section III. Requestor Data

The company/individual initiating this request.

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

First Name/Middle Initial/Last 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 Number/Ext./Fax 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? Yes/No. Is Company Foreign Owned, Controlled or Influenced (FOCI)? Yes/No

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

Company Phone/Fax 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. If working on more than one contract, submit a base access request for each contract supported.

Contract Number: Provide the 13-character contract number that the contractor/visitor 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).

Section VI. Contractor/Visitor Data

Information 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 Name/Middle Initial/Last Name: Provide first name, middle initial and last name of the 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.

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: Check this line if there is no workspace provided for the contractor on 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 ID/Hard Badge? Yes/No

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, NAVAIR at Pax 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.

UIC: 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 NAVAIR/NAWCAD/NAS organization, provide a valid six-character team code. Provide up to 5 team codes as applicable. At least one is required. Example: I21300. To find Team Code Listing, visit this site: ftp://otrs.navair.navy.mil/OTRS/TEAM%20CODES/.

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? Yes/No.

OFF-SITE

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

Work Country: Provide the contractor’s work country.

Work Phone/Fax 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 Visited/Building 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.

CONTRACTOR BASE ACCESS VISIT REQUEST INFORMATION

For instructions and definitions, see next page.

INSTRUCTIONS

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INSTRUCTIONS

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Privacy Act of 1974: This document 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 document is to be stored in a locked cabinet or secured room.

Privacy Act of 1974: This document 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 document is to be stored in a locked cabinet or secured room

Privacy Act of 1974: This document 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 document is to be stored in a locked cabinet or secured room.