SENSE_WSC_Access_Request_Form.pdf

WSC-0365 Rev D (02/21/17)

NASA/WHITE SANDS COMPLEX

Request for Access for Uncleared Visitor

P.O. Box 9000 Las Cruces, NM 88004

Phone: 575/527-7026/7335 Fax: 575/527-7205 wsc-dl-security@mail.nasa.gov

Company/Organization Information

Date:

Company or Organization:

Address:

City: State/Zip:

Phone: Fax:

Employee Information

Full Name:

Title:

SSN:

Date of Birth:

Place of Birth:

Citizenship:

Dual Citizen: YES NO

WSC Point of Contact: Don Shinners

Purpose of Visit: Space Exploration Network Services and Evolution (SENSE) solicitation site visit

Dates of Intended Visit: June 1, 2017

Certification (Must be signed by a Company Official) I certify the information listed above is true and correct.

Signature Title

Instructions All fields must be completed for each visitor. The information should be signed by a company official who is in a position to certify the information. The letter can be signed by a Program Manager, an HR Representative, or the visitor’s supervisor. It may not be signed by the visitor or their secretary. The letter must be received by the WSC Security Office prior to the visit. The letter may not be hand carried by the individual. Providing this information in advance will expedite entry into the facility.