New Base Access Form.pdf
PDF 406 KB Posted
- Solicitation number
- N62841-26-SIMACQ-SPP10-0003
About this file
This is a NOTU Base Credential Request form (NOTUINST 5512.1L, revised July 14, 2025) used for visitor access to Space Launch Delta (SLD) 45 property at Cape Canaveral, Florida. The form is an administrative template requiring visitors to provide personal identification information including name, date of birth, Social Security number, driver's license number, company affiliation, citizenship status, physical descriptors (gender, height, weight, eye color, hair color), and credential validity dates. Authority for the form derives from Executive Order 9397, the Privacy Act of 1974, DoD Directive 8500.1, and applicable federal security standards including HSPD-12 and FIPS 201.
Visitors must complete the first 11 form entries and mandatory security/safety training via a provided QR code link before submitting to the Visitor Control Center (VCC) via email or fax at 321-853-7859. The VCC operates Monday through Friday from 6:30 a.m. to 3:00 p.m. (excluding federal holidays) and requires presentation of a government-approved picture ID. The sponsoring point of contact (POC) at NOTU determines credential start and end dates. Visit requests not retrieved within 30 days will not be held on standby. Security personnel contacts are provided for Personnel Security (Mary Scoggins, primary), Physical Security (James Capps), Information Security (Paul Carraro), and Industrial Security, with an emergency Security Manager contact (Horace Jackson).
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Text version
NOTUINST 5512.1L
30 Sep 2023; rev1 14 Jul 2025
SPP5512.1/3 (Enclosure 3)
NOTU BASE CREDENTIAL REQUEST
** PLEASE PRINT/TYPE THE FOLLOWING INFORMATION **
NAME OF VISITOR (First, MI, Last)
DATE OF BIRTH (MM/DD/YYYY)
SOCIAL SECURITY NUMBER
(need full SS# or request cannot be processed)
DRIVER’S LICENSE # & STATE
NAME OF VISITOR’S COMPANY
U.S. CITIZENSHIP (Y or N) No- then need Perm Resident Card # GENDER (M or F)
HEIGHT (ft/in)
WEIGHT (lbs)
EYE COLOR
HAIR COLOR
START DATE (MM/DD/YYYY)
(DETERMINED BY POC & SECURITY)
END DATE (MM/DD/YYYY)
(DETERMINED BY POC & SECURITY)
NAME/PHONE# OF NOTU SPONSOR or POC
***SEE PAGE 2 FOR COORDINATION AND DIRECTIONS***
AUTHORITY: E.O. 9397; The Privacy Act of 1974, 5 U.S.C. 522a; DODD 8500.1
PRINCIPAL PURPOSE(S): To provide necessary information to determ ine if applicant meets installation access control requirements IAW HSPD12, DoD 5200.8, DTM 09-12, FIPS201 and AFI 31-113. Use of SSN is necessary to make positive identification of an applicant.
Records in the Defense Biometric Identification System (DBIDS) are maintained to support DoD physical security and information assurance programs and are used for identity verification purposes, to rec ord personal property registered with the DoD and for producing facility management reports. SSN, Driver’s License Number or other acceptable identification will be used to distinguish individuals who request access to Space Launch Delta (SLD) 45 property.
DISCLOSURE: Voluntary. However, failure to provide the requested information may result in denial of an access credential and denial of access to SLD 45 property.
MANDATORY TRAINING COMPLETED DATE
TRAINING QR CODE or LINK: https://forms.osi.apps.mil/r/uNbbFMeq0H
NOTUINST 5512.1L
30 Sep 2023; Rev1 Jul 2025
SPP5512.1/3 (Enclosure 3)
Personnel Security 321-399-6020 Mary.Scoggins@ssp.navy.mil (primary to NOTU)
Physical Security 321-399-6021 James.Capps@ssp.navy.mil (alternate)
321-399-6019 Paul.Carraro@ssp.navy.mil (alternate)
Mary Scoggins -
James Capps-
Paul Carraro -
Information Security
Industrial Security
Horace Jackson – Security Manager
321-399-6022 (alternate)
321-399-6019 Horace.Jackson@ssp.navy.mil (in emergencies)
Visitor fills in first 11 entries and complete mandatory Security/Safety training The Sponsor will determine “Start & End” dates/times Visit Requests will NOT be kept on standby at Visitor Center for more than 30 days.
VISITOR CONTROL CENTER (VCC) REQUIREMENTS:
Present a form of ID which must be a government approved picture ID.
Hours of operation to the VCC is 630 am to 3 pm, Mon-Fri except Federal Holidays.
Phone: 321-853-5261
Directions: VCC is 1 block East of: 555 FL-401, Cape Canaveral, FL 32920 (Seaport Canaveral Corp-Large fuel farm)
Email or fax page 1 to 321-853-7859:
| NAME OF VISITOR First MI Last: |
| DATE OF BIRTH MMDDYYYY: |
| SOCIAL SECURITY NUMBER need full SS or request cannot be processed: |
| DRIVERS LICENSE STATE: |
| NAME OF VISITORS COMPANY: |
| HEIGHT ftin: |
| WEIGHT lbs: |
| EYE COLOR: |
| HAIR COLOR: |
| START DATE MMDDYYYY DETERMINED BY POC SECURITY: |
| END DATE MMDDYYYY DETERMINED BY POC SECURITY: |
| NAMEPHONE OF NOTU SPONSOR or POC: |
| Dropdown1: [YES] |
| Text2: |
| Dropdown3: [M] |
| Date1_af_date: |
File details come from the government source that posted it. Updated .