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.

norma.l.white Sticky Note No PII (SSN/DOB) is required on this form. If a green or white badge is issued, PII will be obtained from the individual's two forms of ID (original birth certificate, active passport, or drivers license) upon arrival at the pass office. A criminal history check is conducted prior to a green badge being issued.

norma.l.white Sticky Note If visit is inside NAVSEA Controlled Areas: CIA, Security Island, CNIA or NWA, please fax to the Security Office, Code 1123, Bldg.29/2 @ 207-438-2451 norma.l.white Sticky Note If use of a lap top is necessary to perform their job during visit, a registration form must be filled out by the visitor and shown to pass office personnel upon arrival. The original will remain with the lap top/visitor during visit.

norma.l.white Sticky Note If checked "Yes" the individual will need to be continuously escorted from Main Gate/Pass Office to site and back to the Main Gate. The individual will be issued a "white escort required badge". The individual is required to be continuously escorted inside Security Islands, CNIA's and NWA's. The nuclear managers of CNIA/NWA's must be notified in advance of their arrival and area sanitized.

norma.l.white Sticky Note If checked "No" the individual will be issued a green badge upon verification of two forms of ID and satisfactory criminal history check. The individual is required to be escorted inside Security Islands, CNIA's and NWA's. The nuclear managers of CNIA/NWA's must be notified in advance of their arrival and area sanitized.

norma.l.white Sticky Note The sponsor is required to obtain the information for the visit and fill out the form. The form should not be sent to the company or visitor for them to fill out. The sponsor is required to sign the form with an electronic or hand written signature.

norma.l.white Sticky Note Please ensure the location is specific. ie Building number etc.