Amendment 0001 - 5500 DBIDS Form.docx

DBIDS ACCESS REQUEST FORM (NAVSHIPYD PTSMH 5500)

SUBMISSION INFORMATION

1. Access Requested For (Full Name):

2. Title:

3. Phone Number :

4. COMPANY NAME :

DBIDS INFORMATION

Is the company requesting access to the installation the primary Contractor Yes☐ No☐ If no, who do they subcontract for:

(IF REQUEST IS FOR MORE THAN ONE PERSON PLEASE ATTACH EMPLOYEE LIST)

COMPANY REQUESTING ACCESS INFORMATION

Company Name (Corporate Legal name):

Company Address :

Company Phone Number (Corporate Office):

Company Local POC:

Email and Phone:

Are Any Personnel Foreign Nationals?

Yes ☐ No ☐ (If Yes provide separate list of Names)

For access to: PORTSMOUTH NAVAL SHIPYARD

Timeframe of Access Required: ☐ 0600-1800 ☐ 1400-2300 ☐ 24 Hours

☐ All Week ☒ M-F only ☐ Weekends Only

SPONSOR INFORMATION (MUST BE SHIPYARD PERSONNEL)

Sponsor Name:

Sponsor Organization:

Sponsor Title:

Sponsor Phone Number:

Sponsor Email Address:

Contract or project number:

Contract or Project ACCESS EXPIRATION Date:

Only ONE request for Company access should be submitted to; PNSDBIDS@navy.mil (all requests for employees are on the 5512 and are carried by the employee to pass and ID once the company is approved) Revision 12/16/19

EMPLOYEES LIST

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