Attachment 6 - DL1818.pdf

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Custodial Services for DLA Distribution Susquehanna, Pennsylvania
Solicitation number
SP330023R0002
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VISIT NOTIFICATION

1. ACTIVITY TO BE VISITED

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE:

DEFENSE LOGISTICS AGENCY

8725 JOHN J. KINGMAN ROAD

FT BELVOIR, VA 22060-6220

PRIVACY ACT STATEMENT

Section 21, 50 U.S.C. 781 et seq.; Executive Order 10450.

To control access to and movement on DoD installations, buildings, or facilities.

Used by General Services Administration Protective Service Personnel for access control and for any of the Blanket Routine Uses published by DLA.

Voluntary. However, failure to provide all the requested information may result in refusal to grant access to the installation, building, or facility.

DLA PRIVACY ACT SYSTEM NOTICE S500.50 DLA-I APPLIES

SECTION I

2. NAME OF REQUESTOR/PREPARER 4. TELEPHONE3. OFFICE CODE

5. DATE(S) OF VISIT 6. POINT OF CONTACT (at facility to be visited) 7. POC TELEPHONE

8. PURPOSE OF VISIT

SECTION II

9.

NAME(S) OF VISITOR(S)

(Last, First, MI)

10.

GRADE/RANk

(IF APP)

11.

Social Security No.

12.

DATE OF BIRTH

13.

DL State & Number

14. 15.

16. TYPED NAME OF SECURITY REPRESENTATIVE

SECTION III

18. ACTIVITY 19. TELEPHONE NUMBER 20. DATE17. SIGNATURE OF SECURITY REPRESENTATIVE

DLA FORM 1818, JUL 96 (EG)

FROM: TO:

PerFORM (DLA)

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Text5: 6/06/2023
Text6: 6/06/2023
Text7: Tim Kielbowick
Text8: 717-770-6128
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Text17: Please fax to both X5480 & X8146.
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