PH-SYD_IMF_5512-28_Contractor_VR_Rev__8-14.pdf

CONTRACTOR VISIT REQUEST TO PEARL HARBOR NAVAL SHIPYARD & IMF

PART 1: CONTRACTOR REQUESTING VISIT COMPLETES THIS SECTION Read Privacy Act Statement on page 2. Submit form to GCA a minimum of three (3) weeks in advance of requested visit.

1. FROM: (COMPANY NAME, ADDRESS, POINT OF CONTACT (POC),

PHONE NO., & EMAIL ADDRESS OF VISITING CONTRACTOR/

COMPANY)

2. DATES OF VISIT: FROM ____________ TO ____________

DD MMM YYYY DD MMM YYYY

3. VISITOR(S) REPRESENT(S) (CHECK ONE)

UNITED STATES COMMERCIAL INTEREST

FOREIGN OWNED, CONTROLLED, OR INFLUENCED

COMMERCIAL INTEREST

OTHER: __________________________________________

4. TO: COMMANDER

PEARL HARBOR NAVAL SHIPYARD & IMF

667 SAFEGUARD ST., SUITE 100

PEARL HARBOR, HI 96860

PASS & ID OFFICE (CODE 1125.2) (808) 471-3596

FAX (808) 471-4261

5. CONTRACT INFORMATION

UNCLASSIFIED CONTRACT? (IF YES, CHECK BOX)

CONTRACT/DELIVERY ORDER NO. ________________________

CONTRACT TITLE: ______________________________________

PERIOD OF PERFORMANCE: _____________________________

PRIME CONTRACTOR: ___________________________________

6. GOVERNMENT CONTRACTING ACTIVITY (GCA) ( ACTIVITY

NAME, ADDRESS, POC, PHONE NO., & EMAIL ADDRESS)

7. FACILITY CLEARANCE LEVEL: TOP SECRET

SECRET

CONFIDENTIAL

INTERIM ____________

CAGE CODE: _______________

CONTRACT REQUIRES ACCESS TO: TOP SECRET

SECRET

CONFIDENTIAL

NNP

8. PURPOSE OF VISIT AND SUFFICIENT JUSTIFICATION FOR THE VISIT TO ALLOW FOR AN ACCESS DETERMINATION. INCLUDE SPECIFIC PHNSY & IMF AREAS TO BE VISITED, I.E. BUILDING NUMBERS, DRY DOCKS, SHOPS, SHIPS, ETC.:

9. DEPT/SHOP/TENANT ACTIVITY/SHIP SPONSORING

OR COORDINATING VISIT (INCLUDE CODE):

10. PHNSY & IMF SPONSOR (Name, phone no. & email address):

11. NAME (Last, First, Middle Initial), TITLE, SSN)

12. PLACE/DATE OF

BIRTH

13. U.S. CITIZENSHIP (Check one)

14. LEVEL OF SECURITY

ACCESS (IF INTERIM,

INDICATE BELOW)

NAME: ___________________

TITLE ___________________

SSN: ___________________

POB: ____________

DOB: _____________

U.S. CITIZEN BY BIRTH

U.S. NATURALIZED NO. __________

DOB: ____________

U.S. NATURALIZED NO.__________

POB: _____________

I CERTIFY THAT: 1) EACH PERSON LISTED ABOVE IS EMPLOYED BY THE CONTRACTED COMPANY, IS TRUSTWORTHY AND REQUIRES ACCESS IN PERFORMANCE OF THE CONTRACT; 2) WE WILL IMMEDIATELY NOTIFY YOU OF ANY CHANGES OF EMPLOYMENT STATUS REGARDING EACH PERSON LISTED, I.E. TERMINATION/RESIGNATION; AND 3) EACH PERSON LISTED HAS BEEN BRIEFED ON THE

SECURITY REGULATIONS AND REQUIREMENTS FOR ACCESS TO PHNSY & IMF SPACES.

15. NAME/TITLE OF CONTRACTOR/COMPANY OFFICIAL (TYPE OR PRINT)

SIGNATURE

DATE

PH-SYD IMF 5512/28 (Rev 8-14)

CONTRACTOR VISIT REQUEST TO PEARL HARBOR NAVAL SHIPYARD & IMF (Continuation)

Part 2: GOVERNMENT CONTRACTING ACTIVITY COMPLETES THIS SECTION (Submit to Shipyard Contract Sponsor two (2) weeks prior to visit.) If the contractor requires access to classified information, send DD Form 254 and its attachments to Shipyard Sponsor. Ensure the DD Form 254 includes access to Restricted Data and/or NNPI information, as applicable.

1. I CERTIFY THAT THIS CONTRACT IS VALID FROM ______________ TO _____________ AND THE CONTRACTOR/COMPANY

DD MMM YYYY DD MMM YYYY

LISTED IN PART 1 NEEDS ACCESS TO PHNSY & IMF SPACES.

2. NAME/ACTIVITY/PHONE NO. & EMAIL ADDRESS (Type or print)

CONTRACTING OFFICIAL’S SIGNATURE

Part 3: SPONSOR COMPLETES THIS SECTION (Submit to Shipyard Pass & ID one (1) week prior to visit). If the contractor requires access to classified information review DD 254 for correct access authorization/security guidance and upon completion, forward to Shipyard Code 1125.4.

1. PEARL HARBOR NAVAL SHIPYARD BADGE REQUIRED FOR THE CONTRACTOR PERSONNEL LISTED IN PART 1:

RED BADGE (Unescorted access to NWAs in Shipyard spaces and the CIA, other classified areas onboard a submarine, classified RD/NNPI.

YELLOW BADGE (Unescorted access to CNIAs in Shipyard spaces and the CIA, unclassified areas onboard a submarine, unclassified NNPI.

GREEN BADGE* (Unescorted access to the CIA, escorted/sanitized access to NWAs* & CNIAs*, and outside hull of submarine in Dry Dock, except for NWAs onboard a submarine.

WHITE BADGE (Unescorted access to unclassified information and non-sensitive Shipyard spaces (No access to NNPI, classified information; no unescorted access to CIA or restricted areas).

Other: _________________________________________________________________________________________

NOTE: *Escorted access to any Shipyard NWAs or CNIAs must be coordinated in advance with the cognizant Department or Project Security Coordinator.

I CERTIFY THAT EACH CONTRACTOR LISTED IN PART 1 REQUIRES OFFICIAL ACCESS TO THE ABOVE AREAS UNDER

THIS CONTRACT.

2. NAME OF AUTHORIZED SYD SPONSOR/CODE/PHONE NO. (Print)

SIGNATURE

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; OPNAVINST 5530.14C, Navy Physical Security; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE: To control physical access to PHNSY&IMF spaces in which the Security Office has responsibilities to identify or verify individuals (military, civilian, or contractor) who require access to a controlled facility for purposes of protecting U.S./Coalition/allied government/ national security areas of responsibility and information; to issue Standard Access Control 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 USE: Use of this form by the PHNSY&IMF Security Office is to collect information that will be retained in the PHNSY&IMF Shipyard Pass and Identification Office (Code 1125.2) for subsequent badge renewals. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3), as follows: to designated contractors, Federal agencies, and foreign governments for the purpose of granting Navy officials access to their facility. The DoD 'Blanket Routine Uses' that appear at the beginning of the Navy's compilation of systems of records notices apply to this system.

DISCLOSURE: Voluntary. However, failure to furnish all information requested may result in denial of issuance of the PHNSY&IMF Standard Access Control badge to individual and denial to access PHNSY&IMF spaces, to include the Controlled Industrial Area.

PH-SYD IMF 5512/28 (Rev 8-14)