K_-_NPTU_Security_Form_-_Prefilled.pdf

NAVAL NUCLEAR POWER

TRAINING UNIT (NPTU)

VISIT REQUEST

CHECK ONE

REPLY REQUIRED

REPLY ONLY IF NEGATIVE

DATE OF REQUEST

FROM: (COMPLETE ADDRESS)

TO: NAVAL NUCLEAR POWER TRAINING UNIT

ATTN: COMMAND SECURITY MANAGER

1260 SNOW POINT ROAD

GOOSE CREEK, SC 29445

FAX: 843‐863‐5994 PHONE: 843‐863‐5688

SPECIFIC PERSON(S) OR SECTION

AT NPTU TO BE VISITED

DEGREE OF ACCESS

REQUIRED

ESCORTED

UNESCORTED

POINT OF CONTACT (YOUR SECURITY MGR)

NAME:

RANK/TITLE:

PHONE:

EMAIL:

ARRIVAL DATE

DEPARTURE DATE

DO THEY HAVE BASE ACCESS (BASE DECAL, ETC.)

YES

NO (If no, you must submit a Base Access request (FORM 74))

PURPOSE OF VISIT/REMARKS

NAME, RANK, TITLE

AND/OR POSITION

SOCIAL

SECURITY

NUMBER

DATE AND

PLACE

OF BIRTH

NATIONALITY

(CHECK ONE)

*If Dual Citizen, annotate which countries*

LEVEL/DATE OF

CLEARANCE

US CITIZEN

*DUAL CITIZEN

IMMIGRANT ALIEN

NAME, RANK, TITLE OF OFFICIAL AUTHORIZING

VISIT/CLEARANCE

SIGNATURE AND DATE

**SECURITY MANAGERS USE ONLY BELOW THIS BOX**

ACCESS REQUEST

APPROVED

DISAPPROVED

BLUE

GREEN

ORANGE

PINK “V”

WHITE “E”

RED “E”

(NR APPROVED)

ACCESS EXPIRES AT 2400 ON

NAME, RANK, TITLE OF

OFFICIAL AUTHORIZING

SIGNATURE / DATE APPROVED

NPTU FORM 5521 (NOV 12)

THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974, 5 U.S.C. 552A

alexander.ludington Sticky Note Accepted set by alexander.ludington alexander.ludington Sticky Note Accepted set by alexander.ludington alexander.ludington Sticky Note Accepted set by alexander.ludington alexander.ludington Sticky Note Accepted set by alexander.ludington alexander.ludington Sticky Note Marked set by alexander.ludington alexander.ludington Sticky Note Marked set by alexander.ludington alexander.ludington Sticky Note Completed set by alexander.ludington alexander.ludington Sticky Note Completed set by alexander.ludington alexander.ludington Sticky Note Completed set by alexander.ludington alexander.ludington Sticky Note Completed set by alexander.ludington

01/28/14

DEPARTURE DATE:

01/28/14

SECMGR