N4019220R1800_Base_Access_Request_Form.pdf

Date:

To: Ms. Elizabeth E. Balajadia, Naval Base Guam (NBG) Visitor Control Center Supervisor From:

Subj: BASE ACCESS REQUEST -

CONTRACT INFORMATION:

Contract No./ Title:

Contract Start & Expiration Date:

Prime Contractor Name:

Prime Contractor Address:

Contractor Coordinator:

(Name, Title & Phone Number)

Project Location(s) on Naval Base Guam Installation:

(Check mark all that apply)

Main Base Apra View Housing Apra Palms Housing NAVMAG Polaris Point Turner Housing Flag Circle JRM Naval Hospital

NCTS

Required Access Dates:

(Applies only when dates differ from the contract dates stated above.) From: To:

Required Access Days & Times:

EMPLOYEE INFORMATION:

On company letterhead, attach list all employee(s), requiring base access under this contract. List your sub-contractor employees separately. See attached page for format guidance.

SPONSOR INFORMATION:

Name & Title:

Command:

Phone No:

Email Address:

The above listed Prime Contractor is authorized to operate on-board Naval Base Guam Installation. The above listed Prime Contractor Coordinator will provide and liaison directly with NBG Visitor Control Center, all required contractor employee information, to include sub-contractor employee information, for the purpose of securing authorized base access credentials.

Government Sponsor Signature:

Other (Specify):___________________________

(e.g. MON-FRI/0600-1800)