RFP Document 13 - CBP Short Term Contractors- Visitor Form_BLANK - Short Term Contractors Template.pdf
PDF 83 KB Posted
- Solicitation number
- 47PB0025R0044
About this file
This is a U.S. Customs and Border Protection (CBP) Short Term Contractor Information Sheet, a multi-page form designed to collect detailed personal and contact information for short-term contractors visiting a CBP facility. The document requires comprehensive details for each visitor, including full name, social security number, date of birth, current address, occupation, place of birth, citizenship status, and identification numbers such as passport or visa details.
The form includes critical submission and security requirements. Contractors must submit the form 72 hours prior to arrival for approval, emailing or faxing it to the Office of Professional Responsibility. All visitors must present a U.S. government-issued photo ID, check in and out at the security desk, and be continuously escorted while on CBP premises. The form includes a Privacy Act notice explaining that the information is collected for security screening purposes, and failure to provide complete information may result in denied access to the CBP facility.
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Text version
CBP Short Term Contractor Information Sheet Date Submitted: From:
Contract Company Information CBP Agency Information
Contract Company Name CBP Location Address (Location, Building, Floor, Room #)
Contract Company Address Visitor Escort Full Name (DHS/CBP Employee Only)
Contract Company POC (First & Last Name) Phone Number Email
On Site Contractor POC (First & Last Name) Phone Number Phone Office Phone Mobile
Date(s) and Time(s) of Visit
From Date Time To Date Time
Purpose of Visit:
Provide all below information
# Last Name(s) First Name Middle Name Social
Security Number
DOB
MM/DD/YYYY Current Full Address Occupation POB (City, State/
Country)
U.S.
Citizen (Y/N)
A#, Visa#, Passport # (If NON-USC
Passport # Required)
DL
State Issued
Drivers License #
SUBMISSION: The Office of Professional Responsibility requires a mandatory submission of 72 hours prior to arrival of visitor(s) in order for any visitor to be considered for approval. Email request to SMDSECURITYSERVICESBRANCH@cbp.dhs.gov or fax to the Office of Professional Responsibility, ATTN: Security Management Division at 202-344-1860.
NOTICE: All visitors must present a U.S. Government issued Photo Identification Card. All visitors must check in at the Security Desk upon arrival and check out at the desk upon departure. Visitor escorts are responsible for constant escort of visitors. The designated escort must accompany visitors at all times, to include returning visitors back to the front desk upon departure. Any visitors found in U.S. Customs and Border Protection space without an escort will be immediately reported to security and escortedout of CBP space. One escort must be provided for every four visitors (1-4), depending on Vetting status one escort may be required for evey person (1-1).
PRIVACY ACT NOTICE: This information is provided to PL 93-579 (Privacy Act of 1974). The purpose of this document is provide information necessary for a minimum security check prior tolimited authorized access to U.S. Customs and Border Protection facility. Failure to provide this information may result in denial of access.
# Last Name(s) First Name Middle Name Social
Security Number
DOB
MM/DD/YYYY
Current Full Address Occupation POB (City, State/ Country)
U.S.
Citizen (Y/N)
A#, Visa#, Passport # (If NON-USC
Passport # Required)
DL
State Issued
Drivers License #
SUBMISSION: The Office of Professional Responsibility requires a mandatory submission of 72 hours prior to arrival of visitor(s) in order for any visitor to be considered for approval. Email request to SMDSECURITYSERVICESBRANCH@cbp.dhs.gov or fax to the Office of Professional Responsibility, ATTN: Security Management Division at 202-344-1860.
NOTICE: All visitors must present a U.S. Government issued Photo Identification Card. All visitors must check in at the Security Desk upon arrival and check out at the desk upon departure. Visitor escorts are responsible for constant escort of visitors. The designated escort must accompany visitors at all times, to include returning visitors back to the front desk upon departure. Any visitors found in U.S. Customs and Border Protection space without an escort will be immediately reported to security and escortedout of CBP space. One escort must be provided for every four visitors (1-4), depending on Vetting status one escort may be required for evey person (1-1).
PRIVACY ACT NOTICE: This information is provided to PL 93-579 (Privacy Act of 1974). The purpose of this document is provide information necessary for a minimum security check prior tolimited authorized access to U.S. Customs and Border Protection facility. Failure to provide this information may result in denial of access.
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