Attachment 05 One Time Roster Form.xlsx

XLSX spreadsheet 59 KB Posted May 20, 2021

Attached to: Camp Fuji Gate Construction Federal contract opportunity
Solicitation number: N40084-21-B-8301
Issued by: Department of the Navy Naval Facilities Engineering Command

About this file

Written by GovTribe AI · Dec 28, 2023

This document contains a roster form and instructions for sponsoring visitors to Camp Fuji in Japan. The form collects sponsor information including name, rank, phone numbers and details of the proposed visit. It also collects visitor information such as name, nationality, address, passport number, driver's license number and vehicle license plate if applicable. The sponsor is responsible for total control of non-SOFA guests in accordance with the base regulations and must submit the completed roster to the Provost Marshal's office at least one week prior to the proposed visit date.

The related federal contract opportunity is solicitation number N40084-21-B-8301 for Camp Fuji gate construction work. The solicitation seeks offers for improvements to the gates at Camp Fuji and is issued by the Naval Facilities Engineering Command under the Department of the Navy.

View the file

Other files for this federal contract opportunity

Other files attached to Camp Fuji Gate Construction, newest first.
File	Type	Posted
N40084-21-B-8301-0002 - PPI Responses.pdf	PDF	Jun 7, 2021
N33191-21-B-8301-0001.pdf	PDF	May 20, 2021
Attachment 04 Pre-Bid Inquiry Form.xlsx	XLSX spreadsheet	May 17, 2021
N40084-21-B-8301 - Invitation for Bid (IFB) - Camp Fuji.pdf	PDF	May 17, 2021
Attachment 03 Site Visit Request Form.xlsx	XLSX spreadsheet	May 17, 2021

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PAGE1

ONE TIME / MULTIPLE ACCESS ROSTER Page 1 of 1 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.	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.
b.	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.
Carabeo, Chito Bong F.				315-264-3143	0467-63-3143

e. DESTINATION / INSTALLATION

f. PURPOSE

g. TYPE OF REQUEST

Camp Fuji, Japan

Site Visit

ONE TIME

MULTIPLE

h. MULTIPLE ACCESS

i. MULTIPLE ACCESS

j. SPONSOR'S SIGNATURE

EFFECTIVE DATE

EXPIRATION DATE

27-May-2021

3. VISITORS INFORMATION

a. VISIT DAY

b. VISIT TIME

c. TOTAL (PERSONAL)

d. TOTAL (VEHICLE)

e. GATE NO.

27-May-2021

FROM

945

1100

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	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

CATC FUJI PMO FORM , MAR 2014 PREVIOUS EDITIONS ARE OBSOLETE. V2.70 PM

ONE TIME / MULTIPLE ACCESS ROSTER	Page	2	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

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

ｽﾎﾟﾝｻ-情報入力

スポンサー情報入力 Sponsor's Information

作成日 Date request

依頼者氏名 Name of Sponsor

身分 Job tiltle

職場電話番号 Work Phone

自宅電話番号（携帯電話番号等）

訪問先 Destination of visit

目的 Purpos

訪問者情報 Visitor's Information
訪問日 Date of visit
訪問時間 Time visit	ＦＲＯＭ		ＴＯ
		～
入出門ゲートGate Entry

上記の二重枠内へ各種情報を入力すること

ゲスト情報入力

No	国名 (Nationality)	名前（漢字） Name in Kanji	名前（英文） Name in English	NAME2（カタカナ） Name in Katakana	住所 Address	電話番号（携帯電話） Cell Phone No.	PASSPORT NO.	DRIVER'S LICENSE NO.	車両番号 License Plate No.	所属等 Company
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File details come from the government source that posted it. Updated May 20, 2021.