J-15_Non-Mariner_Maint_KTR_Vetting_Sheet.pdf

Ship Name:

Ship Flag:

Submission Date:

Submitted by:

Contact Info:

PRIVACY ACT STATEMENT (1974)

LAST NAME FIRST NAME MIDDLE NAME RATING or POSITION COMPANY NAME VISIT START DATE DATE OF BIRTH SSN (USA Only) PASSPORT # NATIONALITY 0 SMITH ROBERT (If Applicable) AB/CONT OPCO/CONTRACTING CO. MM/DD/YYYY MM/DD/YYYY 123456789 123456789 (Country listed on Passport)

AUTHORITY:

PRINCIPAL PURPOSE(S):

ROUTINE USE(S):

DISCLOSURE:

SECNAVINST 5211.5E, E0 9397.

To enable U.S. Navy (MSC) to screen personnel against relevant El Paso Intelligence Center (EPIC) databases in support of unescorted access to vessels over which MSC has control.

The information below will be used to ensure the protection and safety of MSC and DOD personnel and assets, and may be furnished to other EPIC vetted personnel or DoD Law enforcement components who have a "Need to Know" the Information in the performance of their duties.

Voluntary; however, failure to provide information may affect the approval of, or type of access to MSC vessels.

MSC/EPIC FORCE PROTECTION REQUEST SUBMISSION TEMPLATE (Non-Mariner Maintenance Contractor) (Revision 8 (v4)- 20 Sep2017)

FOUO-PRIVACY SENSITIVE. ANY MISUSE OR UNAUTHORIZED DISCLOSURE MAY RESULT IN BOTH CIVIL AND CRIMINAL PENALTIES EMAIL SUBJECT LINE to read: FOUO - PRIVACY SENSITIVE - EPIC - PM[#] [PM POC (first 3 letters)] - [SHIP NAME] - [list TYPE (ie CREW, CONTractors, etc)].

Examples: FOUO - PRIVACY SENSITIVE - EPIC - PM5 HUN - BRITTIN - CREW ; FOUO - PRIVACY SENSITIVE - EPIC - MSC OVE - LARAMIE - CONT CONTACT INFORMATION OF PERSON WHO SUBMITTED REQUEST (Phone or Email).