Attachment_3_-_(Site_Visit)_Request_Form.pdf
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- Solicitation number
- N6945018R0902
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VISIT REQUEST PRIVACY ACT STATEMENT ON REVERSE
VISITOR CLEARANCE DATA
OPNAV 5521/27 (REV. 1-75) S/N 0107-LF-055-2235
CHECK ONE
REPLY REQUIRED
REPLY ONLY IF NEGATIVE
FROM (COMPLETE ADDRESS OF REQUESTING ACTIVITY) DATE OF REQUEST
SPECIFIC PERSONNEL OR
SECTION OF COMMAND TO
BE VISITED
TO (COMPLETE ADDRESS OF REQUESTING ACTIVITY)
FOLD ON THIS LINE
DURATION OF VISIT (ARRIVE) DEPART DEGREE OF ACCESS REQUIRED
PURPOSE OF VISIT/REMARKS (IF THE VISIST IS TO A CONTRACTOR FACILITY, INCLUDE CONTRACT NUMBER IF APPROPRIATE)
NAME, RANK, TITLE OR POSITION AND
SOCIAL SECURITY NUMBER
DATE AND PLACE
OF BIRTH
NATIONALITY LEVEL OF SECURITY
CLEARANCE
US CITIZEN
IMMIGRANT ALIEN
US CITIZEN
IMMIGRANT ALIEN
US CITIZEN
IMMIGRANT ALIEN
US CITIZEN
IMMIGRANT ALIEN
US CITIZEN
IMMIGRANT ALIEN
US CITIZEN
IMMIGRANT ALIEN
NAME, RANK AND TITLE OF OFFICIAL AUTHORIZING VISIT AND CLEARANCE SIGNATURE
COPY TO
| REPLY ONLY IF NEGATIVE: On |
| DATE OF REQUEST: |
| TO COMPLETE ADDRESS OF REQUESTING ACTIVITY: PUBLIC WORKS DEPARTMENT |
BLDG 2015
KINGS BAY NSB
SPECIFIC PERSONNEL OR SECTION OF COMMAND TO BE VISITED: MARIO AGUIRRE
(912) 573-2368
| DEPART: 12JUN18 |
| DEGREE OF ACCESS REQUIRED: 12 |
| PURPOSE OF VISITREMARKS IF THE VISIST IS TO A CONTRACTOR FACILITY INCLUDE CONTRACT NUMBER IF APPROPRIATE: PRE-PROPOSAL CONFERENCE AND SITE VISIT FOR JOB ORDERING CONTRACT (JOC) RBC PUMP HOUSE B3046 ROOF AND SIDING REPLACEMENT PROJECT, SOLICIATION N69450-18-R-0902. |
| NAME RANK TITLE OR POSITION AND SOCIAL SECURITY NUMBERRow1: |
| DATE AND PLACE OF BIRTHRow1: |
| LEVEL OF SECURITY CLEARANCERow1: |
| NAME RANK TITLE OR POSITION AND SOCIAL SECURITY NUMBERRow2: |
| DATE AND PLACE OF BIRTHRow2: |
| LEVEL OF SECURITY CLEARANCERow2: |
| NAME RANK TITLE OR POSITION AND SOCIAL SECURITY NUMBERRow3: |
| DATE AND PLACE OF BIRTHRow3: |
| LEVEL OF SECURITY CLEARANCERow3: |
| NAME RANK TITLE OR POSITION AND SOCIAL SECURITY NUMBERRow4: |
| DATE AND PLACE OF BIRTHRow4: |
| LEVEL OF SECURITY CLEARANCERow4: |
| NAME RANK TITLE OR POSITION AND SOCIAL SECURITY NUMBERRow5: |
| DATE AND PLACE OF BIRTHRow5: |
| LEVEL OF SECURITY CLEARANCERow5: |
| NAME RANK TITLE OR POSITION AND SOCIAL SECURITY NUMBERRow6: |
| DATE AND PLACE OF BIRTHRow6: |
| LEVEL OF SECURITY CLEARANCERow6: |
| NAME RANK AND TITLE OF OFFICIAL AUTHORIZING VISIT AND CLEARANCE: MARIO AGUIRRE, CIV, NAVFAC SE, PWD |
| COPY TO: |
| FROM: |
| REPLY REQUIRED: Off |
| US CITIZEN 1: Off |
| IMMIGRANT 1: Off |
| US CITIZEN 2: Off |
| IMMIGRANT 2: Off |
| US CITIZEN 3: Off |
| IMMIGRANT 3: Off |
| US CITIZEN 4: Off |
| IMMIGRANT 4: Off |
| US CITIZEN 5: Off |
| IMMIGRANT 5: Off |
| US CITIZEN 6: Off |
| IMMIGRANT 6: Off |
| ARRIVE: 12 JUN 18 |
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