5530-50 (03.21) - SWFLANT Access Request.pdf

SWFLANT Visit Request Request Date:

This form is for use by commands or organizations that do not have clearances.

The form must be completed and signed by the command or organization Security Representative of the visitor(s). (SWFLANT personnel are not authorized to sign this form).

This form will not be accepted unless all fields are completed and the form is signed by the requesting official.

Requesting Organization Information

Command/company name: Visit date(s):

to

Complete address:

Requesting organization POC: POC Phone #:

Contract #: If subcontractor, list prime contractor: Contract expiration date:

SWFLANT Sponsor/POC: Sponsor/POC Phone #:

Purpose of visit (Be as specific as possible. List project description.):

Areas to be Visited (may require escorted access)

(3) Submarines (4) EHW (5) ESB (6) Controlled Area (7) TRF Waterfront (10) Port Ops

(12) COA Gate (L) Limited Area Exclusion Areas (Escorted): SWFLANT SSBN

Personal Data

Name, Rank, Title/Position (Full legal name)

Full Social Security #

Date of Birth Place of Birth US Citizen NCIC Date

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Requesting Security Official Name: Title:

Requesting Security Official Signature: Date:

SWFLANT Use Only

Authorized By Name:

Authorized By Signature: Date

SUBASE Badge Access Codes: FROM: TO:

Exclusion Access Codes: FROM: TO:

SWFLANT 5530/50 (REV 3/21)

Privacy Act Statement

AUTHORITY: This information is provided pursuant to USC 552.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.

SUB:SWF:

CUI//PRVCY

(when filled in)

CUI//PRVCY

(when filled in)