SIAD Form 1246 Visitor Request Form.pdf

SIERRA ARMY DEPOT VISITOR REQUEST FORM

Proponent Office: Directorate of Emergency Services. Prescribing Reference: AR 190-13

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 United States Code, Section 3013; DoDI 5200.08, Security of DoD Installations and Resources and the DoD Physical Security Review Board (PSRB), Army Regulation 190-13; The Army Physical Security Program.

PRINCIPLE PURPOSE: This form will be used to gather information that will be used to determine the fitness of an individual requiring physical access to Sierra Army Depot (SIAD). All unescorted persons entering a DoD installation must have a valid purpose to enter, have their identity verified and vetted, be issued, or in possession of, an authorized and valid access credential. Installation government representatives are required to query the National Crime Information Center (NCIC) database to vet the claimed identity of a visitor and to determine their fitness using biographical information including, but not limited to, the person's name, date of birth, and social security number.

ROUTINE USES: The information solicited on this form may be made available as a routine use to other government agencies and for law enforcement and administrative purposes to facilitate filing and retrieval.

DISCLOSURE: Information is voluntary. However, failure to furnish requested information may delay or result in the denial of access to

SIAD.

NAME: AKA:

(Last, First, Middle)

SSN: __________-_________-___________

DRIVER’S LIC. #: STATE:

HOME ADDRESS:

DATE OF BIRTH: SEX:

EYE COLOR: HAIR COLOR:

WEIGHT: HEIGHT:

PLACE OF BIRTH: CITIZENSHIP:

(STATE OR COUNTRY) (USA, US NATIONAL, VISA, PERM. RESIDENT, TEMP WORKER, ETC.)

PURPOSE OF VISIT:

AREA(S) TO BE VISITED:

DATE OF ARRIVAL:

ORGANIZATION (COMPANY):

WORK PHONE NUMBER: EMERGENCY CONTACT:

POC AT SIERRA: POC PHONE NUMBER:

___________________________________FOR OFFICIAL USE ONLY________________________________________________

ACCESS GRANTED: YES ESCORT REQUIRED NO DRIVING DENIED

L.E. DIVISION CLETS/NCIC DATE: __________________ VCO/NCIC OPERATOR: ____________________________________

NOTES: _______________________________________________________________________________________________________________________________

SIAD Form 1246, RN: 190-13b, Rev. June 2024 PREVIOUS EDITION IS OBSOLETE

CELL/HOME NUMBER:

Jacqueline.Beauchman Highlight

Jacqueline.Beauchman Highlight

6.2.0.20160331.1.924316