PH-SYDIMF_5512-33_Rev_(12-13)_Escorted_Visit.pdf

REQUEST FOR ESCORTED VISIT TO PEARL HARBOR NAVAL SHIPYARD & IMF

(Continuation for Government Contracting Activity, Sponsor on next page)

Part 1: ACTIVITY/CODE/SHIP REQUESTING VISIT COMPLETES THIS SECTION. (NOTE: THIS FORM IS ONLY FOR UNCLASSIFIED CONTRACTS/VISITS). Read Privacy Act Statement on page 2. Submit form to PHNSY & IMF Code 1125.2, Pass & ID Office, at least two (2) weeks in advance of visit. If this visit involves a Foreign Owned, Controlled or Influenced Commercial or Government Interest, submit request three (3) weeks in advance.

1. FROM: (REQUESTING VISIT)

ACTIVITY:

CODE:

SHIP:

POC NAME:

PHONE NO.:

EMAIL ADDRESS:

2. DATES OF VISIT: FROM: TO:

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

UNITED STATES COMMERCIAL INTEREST (SEE PART 2 & 3)

FOREIGN OWNED, CONTROLLED, OR INFLUENCED

COMMERCIAL OR GOVERNMENT INTEREST, LIST COUNTRY:

OTHER:

4. VISITING ACTIVITY/COMPANY

ACTIVITY:

COMPANY:

ADDRESS:

POC NAME:

PHONE NO.:

EMAIL ADDRESS:

CAGE CODE OR DUNS ID:

5. CONTRACT/SOLICITATION INFORMATION

CONTRACT NO.:

DELIVERY ORDER NO.:

SOLICITATION NO.

CONTRACT TITLE:

PERIOD OF PERFORMANCE:

PRIME CONTRACTOR:

6. GOVERNMENT CONTRACTING ACTIVITY (GCA) OR

DESIGNATED COR (ACTIVITY NAME, ADDRESS, POC, PHONE

NO., & EMAIL ADDRESS)

7. ESCORTING ACTIVITY/CODE/SHIP, POC NAME, PHONE NO. & EMAIL

ADDRESS (IF DIFFERENT FROM BLOCK 1)

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

10. PLACE/DATE OF BIRTH

11. COUNTRY OF CITIZENSHIP

(If naturalized, add naturalization number)

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

CONTRACT/SOLICITATION OR HAS A REASON RELATED TO THE PHNSY & IMF MISSION.

13. NAME OF AUTHORIZED SYD SPONSOR/CODE/PHONE NO. (print)

SIGNATURE

DATE

PH-SYD/IMF 5512/33 (Rev 12-13)

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

Part 2: GOVERNMENT CONTRACTING ACTIVITY OR DESIGNATED COR COMPLETES THIS SECTION

(If a contract is involved, complete and return to the Activity/Code/Ship listed in Block 1).

(Check applicable boxes)

1. a. I CERTIFY THAT THE CONTRACT INFORMATION IN PART 1, BLOCK 5 IS VALID AND THE

CONTRACTOR/COMPANY LISTED IN BLOCK 4 NEEDS ACCESS TO PHNSY & IMF SPACES.

b. I VERIFIED THAT THE CONTRACTOR/COMPANY LISTED IN PART 1, BLOCK 4 (INCLUDING IT’S PARENT COMPANY) IS NOT FOREIGN OWNED, CONTROLLED OR INFLUENCED OR DOES NOT HAVE ANY

FOREIGN (COMMERCIAL OR GOVERNMENT) INTEREST AS DEFINED BY DOD 5220.22-M (SEE

DEFINITION BELOW).

FOREIGN INTEREST IS DEFINED BY DOD 5220.22-M

(NATIONAL INDUSTRIAL SECURITY PROGRAM OPERATING MANUAL) AS:

"ANY FOREIGN GOVERNMENT, AGENCY OF A FOREIGN GOVERNMENT, OR REPRESENTATIVE OF A

FOREIGN GOVERNMENT; ANY FORM OF BUSINESS ENTERPRISE OR LEGAL ENTITY ORGANIZED,

CHARTERED OR INCORPORATED UNDER THE LAWS OF ANY COUNTRY OTHER THAN THE U.S. OR ITS POSSESSIONS AND TRUST TERRITORIES, AND ANY PERSON WHO IS NOT A CITIZEN OR NATIONAL OF

THE UNITED STATES."

2. CONTRACTING OFFICIAL/COR’S NAME/PHONE NO. & EMAIL

ADDRESS (Type or print)

SIGNATURE

DATE

Part 3: INSTRUCTIONS FOR SPONSOR (BLOCK 1) FOR VISITS THAT ARE NOT CONTRACT RELATED

1. IF THE COMPANY (INCLUDING IT’S PARENT COMPANY) DOES NOT HAVE ANY FOREIGN INTEREST, YOU WILL NEED TO HAVE A COMPANY OFFICIAL (I.E. PRESIDENT, VICE PRESIDENT, BOARD MEMBER, GENERAL MANAGER) PROVIDE A SIGNED/DATED STATEMENT ON COMPANY LETTERHEAD THAT STATES THE FOLLOWING OR HAVE HE

OR SHE COMPLETE THE STATEMENT BELOW:

"I, __________________________________________, VERIFY THAT ___________________________DOES NOT HAVE

(NAME/TITLE) (INSERT COMPANY NAME)

ANY FOREIGN INTEREST AS DEFINED BY DOD 5220.22-M."

2. ATTACH THE STATEMENT TO THIS FORM (AS APPLICABLE) WHEN YOU SUBMIT IT TO CODE 1125.2.

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.