NOTU_Base_Access_req_2022.pdf

NOTUINST 5512.1K

14 Sep 2022

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***

All Visitors to CCSFS must provide the above information and email or fax to 321-853-7859:

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.

NOTUINST 5512.1K

July 2022

SPP5512.1/3 (Enclosure 3)

Personnel Security 321-339-6020 Mary.Scoggins@ssp.navy.mil (primary to NOTU) Mary Scoggins -

Paul Carraro - Information Security 321-339-6019 Paul.Carraro@ssp.navy.mil (alternate)

Visitor fills in first 11 entries and verify the information is correct.

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)

SPP44X

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