Local_Visitor_Request_Form.pdf

LOCAL VISITOR REQUEST FORM

Form PTSMH 5521/1 (REV 11 OCT 2012) ALL OTHER FORMS ARE OBSOLETE

To: Pass & ID Office, Building 384 Visit Start Date: _________________ (Completed form may be faxed to 207-438-2669)

Visit End Date: __________________

From: Shop/Code/Org: ______________________________________________________________________

Is this a Classified Visit? YES_____ NO_____ Is this an Escorted Visit? YES_____ No_____ (Classified Visit: Submit through JPAS to SMO 39040 or official letterhead attached with clearance information)

Company or Organization Name:_______________________________________________________________

Purpose and Location of Visit (Bldg):____________________________________________________________

VISITOR(S) INFORMATION: (Additional typed/written page is authorized for multiple visitors)

US Citizen State of NAME: Last, First, Middle Initial (Yes or No) Residence If NOT Escorted: SSN/DATE OF BIRTH

Special Requirements (Check as appropriate): Questions? Contact your Shipyard Visit Sponsor

Camera Permit: Yes____ No____ Laptop/PDA Permit Yes____ No____ Access to U-NNPI Yes____ No____ Shipboard Access Yes____ No____

PNS Sponsor (POC): (printed name) _________________________________ Phone:__________

Signature: _______________________________________Date:_____________

---------------------------------------------------------Internal Control Use Only ----------------------------------------------------------- Route to: 1710 ______ 1730 _______ Visit Request Serial No.

NAVSEA SACB Required/COLOR: _______________________ Escort Required (Y/N) __________ Escort (s) Briefing: Yes______ No______ Date: _________________

Reviewed by: ____________________________Date: _______________Approved:______ (Check)

PRIVACY ACT STATEMENT

Title 5 USC §301 authorizes collection of the information contained in this form. The primary use of this information is to adjudicate access to Portsmouth Naval Shipyard, its facilities and to maintain visit statistics. The Blanket Routine Uses that appears at the beginning of the Navy’s compilation of systems of records notices applies to this form. Executive Order 9397 (22 Nov 1943) as amended by Executive Order 13478 (18 Nov 2008), authorizes use of the Social Security Number (SSN#) to distinguish individuals.

Further, Department of Defense Instruction 1000.30 (12 Apr 2012) is also applicable. Furnishing your SSN#, as well as other data, is strictly voluntary. However, failure to do so may result in denying your request.

norma.l.white Cross-Out norma.l.white Sticky Note No PII is required on this form. If a green badge is issued, PII will be obtained from visitor upon arrival at pass office, prior to badge being issued.