Site Visit Contractor Form.pdf

UNITED STATES MARSHALS SERVICE

Northern District of West Virginia

Contractor Access Form

Please complete this form if your agency requires a contractor to enter the Federal Courthouse to perform an ordered task. Form must be completed, in its entirety, and submitted to USMS for approval, no less than 24 business hours prior to the scheduled ordered task.

When completed, please email this form to: alphonso.wideman@usdoj.gov, or fax to: (304) 267-9369

After Hours Business Hours Date(s) Time(s)

Sponsoring Agency: Sign/Date:

Agency Primary Contact Name: Primary Contact Phone:

Agency Alternate Contact Name: Alternate Contact Phone:

Agency After Hours Contact Name: After Hours Contact Phone:

Company Name:

Company Point of Contact:

Company Phone Number:

HSPD-12/Prox

(Mark if Yes)

Type of work to be performed and in what areas (floor/office number, courtrooms, etc.):

Approved by (USMS):

(This form must be approved by USMS before it can be issued to security) mailto:alphonso.wideman@usdoj.gov

Contractor Information:

Name

(Last, First, MI) DOB Sex/Race

Length Requested

Begin Date

End Date Date of

Background

Contractor’s Vehicle Information:

ONLY if using secured parking lot

Make Model Color License Plate

State Number

Contractor Tool List:

Contractor must provide a complete list of tools and equipment being transported inside the Federal Courthouse (Items can be waved with USMS Approval)