Attachment G - Site Visit Request Form.pdf

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NSWCPD VISITORS REQUEST

NSWCPHILADELPHIADIV 5512/8 (JUN-2024)

REF: NSWCPD SOP 5530.7

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PREVIOUS EDITIONS ARE OBSOLETE

PART I. GENERAL INFORMATION

The Sponsor / COR request a temporary visitor badge, SACB, or access added to their CAC / TWIC or Day Pass to be issued to the below listed person(s) based on the information provided below in this request (information must be typed for NSWCPD to process):

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; OPNAVINST 5530.14E, Navy Physical Security and Law Enforcement Program; Marine Corps Order P5530.14, Marine Corps Physical Security Program Manual; and E.O. 9397 (SSN), as amended.

PURPOSE: To control physical access to DoD, Department of the Navy (DON) or U.S. Marine Corps Installations/Units controlled information, installations, facilities, or areas over which DoD, DON or USMC has security responsibilities by identifying or verifying an individual through the use of biometric databases and associated data processing/information services for designated populations for purposes of protecting U.S./Coalition/allied government/ national security areas of responsibility and information; to issue badges, replace lost badges and retrieve passes upon separation; to maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/exit times of personnel.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act of 1974, as amended, these records contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a (b) (3) as follows: To designated contractors, Federal agencies, and foreign governments for the purpose of granting Department of the Navy officials access to their facility. The DoD Blanket Routine Uses set forth at the beginning of the Department of Navy's compilation of system of records notices may apply to this system.

DISCLOSURE: Voluntary; however, failure to furnish the requested information may delay or lead to denial of access.

PART II. VISITING CONTRACTOR

PART III. SPONSOR (REQUIRED TO SIGN BELOW ACKNOWLEDGING THEIR RESPONSIBILITIES)

Sponsor will advise all guests of NSWCPD entry procedures and limitations while at PNY to include required safety regulations and security procedures.Sponsor is responsible for keeping the NSWCPD Visitor Center up to date about the need of access for all of their guests. Any change in status must be communicated immediately to the Visitors Center. Sponsor is the point of contact for any police or security actions concerning their guests. Sponsor acknowledges that anyone named on the attached form that has disqualifying factors on a criminal check or has been barred from a military installation will be denied entry. The sponsor is responsible for verifying the results of these checks. Sponsor of any Day Visitor must escort that guest at all times in Government facilities.

PART IV. ACCESS SECTION (SPONSOR / COR)

21. COMMAND VISITING:

PART V. NSWCPD SECURITY SECTION (VERIFICATION)

30. NSWCPD SECURITY:

PART I. GENERAL INFORMATION

1. FULL NAME OF SPONSOR (GOV'T SPONSOR OR COR). Insert full name of sponsor.

2. SPONSOR / COR PHONE NUMBER. Insert sponsor's phone number.

3. SPONSOR / COR EMAIL. Insert sponsor's full email address.

4. SPONSOR BUILDING AND CODE. Insert sponsor's office building and code.

5. FIRST NAME OF VISITOR. Insert visitor's first name.

6. MIDDLE NAME. Insert visitor's middle name.

7. LAST NAME. Insert visitor's last name.

8. Select applicable items.

9. JUSTIFICATION / PURPOSE / MEETING FOR VISIT NEEDED. Insert explanation for submitting request.

10. START DATE OF VISIT. Select start date of visit.

11. END DATE OF VISIT (1-YR MAX LENGTH). Select end date of visit (not to exceed one year from start date).

12. COMPANY OR AGENCY NAME. Insert name of affiliated company / agency.

13. VISITOR CELL PHONE NUMBER. Insert visitor's cell phone number.

PART II. VISITING CONTRACTOR

14. CONTRACT NUMBER. Insert full contract number.

15. CONTRACT EXPIRATION DATE. Select contract expiration date.

16. WILL THE CONTRACTOR BE WORKING WITH CLASSIFIED INFORMATION? Select one of the following:

"Yes" "No"

17. CLEARANCE LEVEL (IF ANY). Select one of the following:

"Confidential" "Secret" "Top Secret" "Top Secret, SCI"

18. CONTRACTOR EMAIL ADDRESS. Insert contractor's full email address.

PART III. SPONSOR (REQUIRED TO SIGN BELOW ACKNOWLEDGING THEIR RESPONSIBILITIES)

19. SPONSOR / COR SIGNATURE. Click to sign.

PART IV. ACCESS SECTION (SPONSOR / COR)

20. BUILDINGS VISITED. Insert all buildings visited.

21. COMMAND VISITING. Insert command visited.

22. COLOR BADGE REQUIRED. Select one of the following:

"Yes" "No"

23. IF YES, COLOR. Select one of the following:

"Red" "Yellow" "Green" "N/A"

24. ACCESS LEVELS (FOUNDRY AND B633 ONLY). Insert 3-digit access level number.

PART V. NSWCPD SECURITY SECTION (VERIFICATION)

25. DISS VAR START DATE. Select DISS VAR start date.

26. DISS VAR END DATE. Select DISS VAR end date.

27. DD5512 RESULTS. Select one of the following:

"Favorable" "Unfavorable" 27a. START DATE. Select start date.

27b. END DATE. Select end date.

28. DAY VISITOR - GOV'T ISSUED ID CHECKED. Select type of government issued identification checked.

"Driver's License" "Social Security Card" "State Identification (ID)" "Common Access Card (CAC)""Other"

29. CLEARANCE LEVEL. Select one of the following:

"Confidential" "Secret" "Top Secret" "Top Secret, SCI"

30. NSWCPD SECURITY. Select one of the following:

"Approved" "Disapproved"

31. SECURITY SPECIALIST WHO VERIFIED. Insert full name of security specialist who verified request.

NSWCPD VISITORS REQUEST INSTRUCTIONS

11.0.0.20130303.1.892433.887364 Robert Sheridan robert.m.sheridan15.civ@us.navy.mil

(215) 897-8633 Bldg 4 / Code 1021