5530-50_SWFLANT_Access_Request.pdf
PDF 164 KB Posted
- Attached to
- REMOVE AND DISPOSE OF DEBRIS Federal contract opportunity
- Solicitation number
- N6470919R0031
About this file
VISIT REQUEST
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Text version
This form is for use by commands or organizations that do not have access to JPAS.
The form must be completed and signed by the command or organization Security Representative of the visitor(s). (SWFLANT personnel can not sign this form).
This form will not be accepted unless all required fields are completed and the form is signed by the requesting official. **Required Fields
SWFLANT ACCESS FORM/VISIT REQUEST
STRATEGIC WEAPONS FACILITY, ATLANTIC
1150 USS LOS ANGELES ROAD
KINGS BAY, GEORGIA 31547-2634
CHECK ONE
Reply Required
Reply Only If Negative
REQUESTING ACTIVITY
FROM (Command/company name and complete address)** ORIGINATING POINT OF CONTACT**
(PHONE & FAX NUMBER)
DATE OF REQUEST: **
SWFLANT SPONSOR AND/OR POINT OF CONTACT AND PHONE NUMBER**
(Requests without a SWFLANT Point of Contact will not be processed)
ARRIVAL DATE:**
DEPARTURE DATE:**
PURPOSE OF VISIT (Be as specific as possible. If limited/exclusion area access is requested, a new request is required for each visit.)**
AREAS TO BE VISITED
SUBMARINES (3) EHW (4) ESB (5) CONTROLLED AREA (6) TRF WATERFRONT (7)
PORT OPERATIONS (10) COA GATE (12) LIMITED AREA (L) DHB EXCLUSION (D) EHW EXCLUSION (E)
RFF (G) MMM EXCLUSION (M) RBC EXCLUSION (R) VMPB EXCLUSION (V) SSBN EXCLUSION (W)
PERSONNEL DATA
NAME, RANK, TITLE OR POSITION**
(Military names must match military ID Card)
**FULL SOCIAL
SECURITY NUMBER
DATE AND PLACE
OF BIRTH**
NATIONALITY**
LEVEL OF
CLEARANCE**
US CITIZEN
DUAL CITIZEN
IMMIGRANT ALIEN
US CITIZEN
DUAL CITIZEN
IMMIGRANT ALIEN
US CITIZEN
DUAL CITIZEN
IMMIGRANT ALIEN
US CITIZEN
DUAL CITIZEN
IMMIGRANT ALIEN
US CITIZEN
DUAL CITIZEN
IMMIGRANT ALIEN
REQUESTING SECURITY OFFICIAL:**
(NAME, TITLE, SIGNATURE)
FOR SWFLANT USE ONLY
SIGNATURE AND DATE OF AUTHORIZING OFFICIAL: BADGE ACCESS CODES LA/EXCLUSION ACCESS CODES
FROM: TO: FROM: TO:
PRIVACY ACT STATEMENT
AUTHORITY: This information is provided pursuant to USC 352.a.
PURPOSE & USE: The purpose of this form is to maintain a record system of identification badges issued to individuals being allowed ready access to SWFLANT Kings Bay.
Routine use of this form is for the maintenance of information regarding individuals to whom identification badges have been issued.
DISCLOSURE: Voluntary, however, if information is not provided individual will not be issued an identification badge affording access to SWFLANT Kings Bay.
SWFLANT 5530/50 (REV 5/09)
| DATE OF REQUEST: |
| SWFLANT SPONSOR ANDOR POINT OF CONTACT AND PHONE NUMBER Requests without a SWFLANT Point of Contact will not be processed: |
| SUBMARINES 3: Off |
| undefined_3: Off |
| undefined_4: Off |
| CONTROLLED AREA 6: Off |
| TRF WATERFRONT 7: Off |
| PORT OPERATIONS 10: Off |
| undefined_5: Off |
| LIMITED AREA L: Off |
| DHB EXCLUSION D: Off |
| EHW EXCLUSION E: Off |
| undefined_6: Off |
| MMM EXCLUSION M: Off |
| RBC EXCLUSION R: Off |
| VMPB EXCLUSION V: Off |
| SSBN EXCLUSION W: Off |
| NAME RANK TITLE OR POSITION Military names must match military ID CardRow1: |
| FULL SOCIAL SECURITY NUMBERRow1: |
| undefined_7: Off |
| undefined_8: Off |
| undefined_9: Off |
| LEVEL OF CLEARANCERow1: |
| NAME RANK TITLE OR POSITION Military names must match military ID CardRow2: |
| FULL SOCIAL SECURITY NUMBERRow2: |
| undefined_10: Off |
| undefined_11: Off |
| undefined_12: Off |
| LEVEL OF CLEARANCERow2: |
| NAME RANK TITLE OR POSITION Military names must match military ID CardRow3: |
| FULL SOCIAL SECURITY NUMBERRow3: |
| undefined_13: Off |
| undefined_14: Off |
| undefined_15: Off |
| LEVEL OF CLEARANCERow3: |
| NAME RANK TITLE OR POSITION Military names must match military ID CardRow4: |
| FULL SOCIAL SECURITY NUMBERRow4: |
| undefined_16: Off |
| undefined_17: Off |
| undefined_18: Off |
| LEVEL OF CLEARANCERow4: |
| NAME RANK TITLE OR POSITION Military names must match military ID CardRow5: |
| FULL SOCIAL SECURITY NUMBERRow5: |
| DATE AND PLACE OF BIRTHRow5: |
| undefined_19: Off |
| undefined_20: Off |
| undefined_21: Off |
| LEVEL OF CLEARANCERow5: |
| DEPARTURE DATE: |
| ARRIVAL DATE: |
| DATE AND PLACE OF BIRTHRow4: |
| PURPOSE OF VISIT Be as specific as possible If limitedexclusion area access is requested a new request is required for each visit: |
| DATE AND PLACE OF BIRTHRow1: |
| DATE AND PLACE OF BIRTHRow2: |
| DATE AND PLACE OF BIRTHRow3: |
| PRINT: |
| CLEAR: |
| Group3: Off |
| FROM: |
| POC PHONE: |
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