Attachment_4_Site_Visit_Request_Form.xls

XLS spreadsheet 98 KB Posted Jul 23, 2019

Attached to: Demolish Building Nos. T-115, 409A, 102 and 51, CATC, Camp Fuji, Japan
Solicitation number: N4008419B0092
Issued by: Department of the Navy Naval Facilities Engineering Command

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Attachment 4 Site Visit Request Form

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File	Type	Posted
N40084-19-B-0092_AM-0002.pdf	PDF	Aug 14, 2019
N40084-19-B-0092_AM-0001.pdf	PDF	Aug 7, 2019
Pre-Bid_Conference_Brief_19B0092.pdf	PDF	Aug 7, 2019
Attachment_1_Performance_Work_Statement.pdf	PDF	Jul 23, 2019
N40084-19-B-0092.pdf	PDF	Jul 23, 2019
Attachment_3_Pre-Bid_Inquiry_Form.xls	XLS spreadsheet	Jul 23, 2019

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PAGE1

ONE TIME / MULTIPLE ACCESS ROSTER

Page

Pages

DATE OF REQUEST

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY:

Title 10, U.S. Code, Section 3013.

PRINCIPAL PURPOSE:

To provide information to officials of the Army responsible for monitoring.controlling visitor's status.

ROUTINE USES:

Information is used to record and assign authorized pass numbers to allow authorized visitors onto U.S. Marine Corps installations.

DISCLOSURE:

Voluntary. Failure to disclose the required information wull result in authorized pass numbers not being issued;

therefore, causing the applicants to have to meet and escort on and off the installation their visitors.

1. INSTRUCTION

A "One Time/Multiple Access Roster" is valid for a single group visit for a specific date and time. It is the sole responsibility of the individual sponsor to

include all information listed. Processing time can be reduced if each sponsor will take the time to legibly list the required information in both English and

Kanji. This roster must be submitted to the Provost marshal, MCIPAC, within one week of the proposed visit.

The sponsor's signature serves as an acknowledgment the sponsor is aware of his/her individual responsibilities to exercise total control over his/her

non-SOFA guests in accordance with the provisions contained in MCIPACO 5512.2 CH1

2. SPONSOR INFORMATION & ACCESS DESCRIPTION

a. TYPED NAME (Last, First MI)

b. RANK

c. DUTY TELEPHONE NO.

d. TELEPHONE NO.

N/A

e. DESTINATION / INSTALLATION

f. PURPOSE

g. TYPE OF REQUEST

Main Gate (Gate no. 4)

SITE-VISIT

ONE TIME

MULTIPLE

h. MULTIPLE ACCESS

i. MULTIPLE ACCESS

j. SPONSOR'S SIGNATURE

EFFECTIVE DATE

EXPIRATION DATE

3. VISITORS INFORMATION

a. VISIT DAY

b. VISIT TIME

c. TOTAL (PERSONAL)

d. TOTAL (VEHICLE)

e. GATE NO.

FROM

NATIONALITY

NAME (Last, First MI)

ADDRESS & TELEPHONE NO.

PASSPORT NO. &

DRIVER'S LICENSE NO.

VEHICLE

PLATE NO.

JAPAN	ENGLISH	ADDRESS		PASSPORT NO.
	JAPANESE	TEL		DRIVER'S LICENSE NO.
JAPAN	ENGLISH	ADDRESS		PASSPORT NO.
	JAPANESE	TEL		DRIVER'S LICENSE NO.
JAPAN	ENGLISH	ADDRESS		PASSPORT NO.
	JAPANESE	TEL		DRIVER'S LICENSE NO.
JAPAN	ENGLISH	ADDRESS		PASSPORT NO.
	JAPANESE	TEL		DRIVER'S LICENSE NO.
JAPAN	ENGLISH	ADDRESS		PASSPORT NO.
	JAPANESE	TEL		DRIVER'S LICENSE NO.
CATC FUJI PMO FORM , MAR 2014			PREVIOUS EDITIONS ARE OBSOLETE.		V2.70	PM

	ONE TIME / MULTIPLE ACCESS ROSTER				Page	2	of	2	Pages	DATE OF REQUEST
	NATIONALITY	NAME (Last, First MI)		ADDRESS & TELEPHONE NO.			PASSPORT NO. &
DRIVER'S LICENSE NO.			VEHICLE

PLATE NO.

JAPAN	ENGLISH		ADDRESS		PASSPORT NO.
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	ENGLISH		ADDRESS		PASSPORT NO.
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	ENGLISH		ADDRESS		PASSPORT NO.
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	ENGLISH		ADDRESS		PASSPORT NO.
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	ENGLISH		ADDRESS		PASSPORT NO.
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	ENGLISH		ADDRESS		PASSPORT NO.
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	ENGLISH		ADDRESS		PASSPORT NO.
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	ENGLISH		ADDRESS		PASSPORT NO.
	JAPANESE		TEL		DRIVER'S LICENSE NO.
ACCESS ROSTER CONTINUED:		SPONSOR'S TYPED NAME			SPONSOR'S SIGNATURE
CATC FUJI PMO FORM				PREVIOUS EDITIONS ARE OBSOLETE.		V2.70	PM

	ONE TIME / MULTIPLE ACCESS ROSTER				Page	3	of	4	Pages	DATE OF REQUEST
										31-Dec-1899
	NATIONALITY	NAME (Last, First MI)		ADDRESS & TELEPHONE NO.			PASSPORT NO. &
DRIVER'S LICENSE NO.			VEHICLE

PLATE NO.

0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
ACCESS ROSTER CONTINUED:		SPONSOR'S TYPED NAME			SPONSOR'S SIGNATURE
CATC FORM , MAR 2014				PREVIOUS EDITIONS ARE OBSOLETE.		V2.70	PM

	ONE TIME / MULTIPLE ACCESS ROSTER				Page	4	of	4	Pages	DATE OF REQUEST
										31-Dec-1899
	NATIONALITY	NAME (Last, First MI)		ADDRESS & TELEPHONE NO.			PASSPORT NO. &
DRIVER'S LICENSE NO.			VEHICLE

PLATE NO.

0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
0	ENGLISH		ADDRESS		PASSPORT NO.
	0		0		0
	JAPANESE		TEL		DRIVER'S LICENSE NO.
	0		0		0
ACCESS ROSTER CONTINUED:		SPONSOR'S TYPED NAME			SPONSOR'S SIGNATURE
CATC FUJI PMO FORM				PREVIOUS EDITIONS ARE OBSOLETE.		V2.70	PM

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