Att 1(k) - Visit Request

(k) Visit Request (Norco)

VISIT REQUEST

VISITOR CLEARANCE DATA

FROM (COMPLETE ADDRESS OF REQUESTING ACTIVITY) UIC N/A

CHECK ONE REPLY REQUIRED

REPLY ONLY IF NEGATIVE

DATE OF REQUEST

ECIFIC PERSONNEL OR SECTION OF COMMAND TO BE VISITED

MAILING ADDRESS

N/A

FOLD ON THIS LINE

DURATION OF VISIT (ARRIVE) (DEPART) DEGREE OF ACCESS REQUIRED

PURPOSE OF VISIT/REMARKS (IF THE VISIT IS TO A CONTRACTOR FACILITY, INCLUDE CONTRACT NUMBER IF APPROPRIATE)

NAME, RANK, TITLE OR POSITION and

SOCIAL SECURITY NO.

LEVEL OF SECURITY CLEARANCE

U.S. CITIZEN

N/A

IMMIGRANT ALIEN

U.S. CITIZEN

IMMIGRANT ALIEN

U.S. CITIZEN

IMMIGRANT ALIEN

U.S. CITIZEN

IMMIGRANT ALIEN

U.S. CITIZEN

IMMIGRANT ALIEN

U.S. CITIZEN

IMMIGRANT ALIEN

COPY TO:

Janet Rigby (janet.rigby@navy.mil)

PRIVACY ACT STATEMENT

OPNAV 5521/27, Visit Request

AUTHORITY: E.O. 11652

PRINCIPAL PURPOSE: Information is obtained to identify personnel visiting activities when such visits are expected to involve access to classified information.

ROUTINE USE: Information provided in the form, when compared with information known to or normally in the possession of an individual, is used in determining whether or not an individual is who he purposts to be when visiting an activity. The information may be disclosed to all those charged at the activity with making the foregoring determination.

DISCLOSURE: (Mandatory or voluntary; consequences, etc.): Completion of OPNAV 5521/27, including the disclosure of your Social Security Number, is voluntary. Failure on your part, however, to answer all questions, or any misrepresentation (by omission or concealment, or by misleading, false, or partial answers), may serve as a basis for denial of the request to visit, or for access to information classified in the national interest pursuant to E.O. 11652.