TE 2 Form 21.docx

U.S. Army Garrison Fort Belvoir at Rivanna Station Instructions for Request for Unescorted Installation Access

This form is used to request unescorted access to U.S. Army Garrison, Fort Belvoir at Rivanna Station by U.S. citizens and Permanent Residents who are not affiliated with Fort Belvoir at Rivanna Station, the Department of Defense (DoD) or other approved federal, state or local government agencies. Individuals with a pre-existing affiliation are generally granted access to the installation and should contact the Access Control Manager at (434) 951-4380 to determine whether this request is necessary. To request access for foreign nationals, contact the Installation Security Manager at (434) 951-4380.

Garrison personnel who are sponsoring contractors, event attendees or other visitors onto the installation will complete the section labeled "THIS SECTION TO BE COMPLETED BY GOVERNMENT SPONSOR" prior to providing the request to applicants, and will provide this instruction page in addition to the application page.

Fields with an asterisk (*) are mandatory. Explanations for each entry on the request are as follows:

VISITOR ORGANIZATION SECTION (to be completed by the organization requesting unescorted access) CO or ORG: Enter the visitor's company or organization name, if applicable.

CO/ORG Point of Contact: Enter the name of the company or organization officer handling the access request, if applicable.

Contract #: Enter the contract number, if applicable (optional).

CAGE Code: Enter the company's CAGE code, if applicable (optional).

Dates of Access Request: Enter the beginning and ending dates of that access to the installation is requested.

Point of Contact Email Address: Provide an email address where the request’s Point of Contact can be reached.

Point of Contact Office #: Provide a telephone number where the request’s Point of Contact can be reached.

GOVERNMENT SPONSOR SECTION (to be completed by the government sponsor overseeing the visit prior to providing the blank form to the intended visitor(s)) Government Sponsor*: Enter the name of the DoD Civilian or Military member responsible for oversight of this visit.

Purpose of Visit*: Enter the purpose of the visit (i.e. contract site survey, training session, etc.)

Sponsor Organization*: Enter the sponsor’s directorate or organization.

Sponsor Telephone #*: Enter the responsible COR's office telephone number.

VISITOR INFORMATION

Last Name: Enter each visitor's full surname.

First Name: Enter each visitor's full first name.

Middle Name: Enter each visitor's full middle name, not just the middle initial.

Gender: Enter each visitor's gender, either "Male" or "Female". Do not use "M" and "F".

Race: Check one block for each visitor to indicate the closest choice for race. The only options allowable for querying the National Crime Information Center (NCIC) Interstate Identification Index (III) are:

Date of Birth: Enter each visitor's date of birth (Month dd, yyyy).

Social Security Number: Enter each visitor's social security number.

State License/ID, U.S. Passport or Permanent Resident #*: Enter the State driver’s license # and State issued, U.S. passport # or Permanent Resident # that will be presented upon entry to the installation.

Requests will be submitted at least ten working days prior to the first date access is requested. Fort Belvoir at Rivanna Station will not be responsible for incomplete processing resulting from late submissions. Requestors may submit additional requests for unescorted access at any time, and may request extensions as necessary. Do not submit a "running" roster that shows previously-approved personnel unless those personnel have expired or are approaching the expiration date of their previously approved access. Handwritten rosters will be accepted, but must be legible. Rosters submitted in any other format that prohibits processing by “cut and paste” may be delayed if data needs to be re-input. Fort Belvoir at Rivanna Station is not responsible for delays caused by Illegible or non-Word submissions.

If there are any questions, please contact access point of contact at (434) 951-4380.

DPTMS (RS) Form 21 Revised 29 OCT 2014

Request for Unescorted Installation Access

For use of this form, see Army Regulation 190-13, "Installation Access" and the "Instructions" page. The proponent agency is DPTMS.

PRIVACY ACT STATEMENT

THIS SECTION TO BE COMPLETED BY COMPANY, ORGANIZATION, OR VISITING INDIVIDUAL. PLEASE REVIEW THE "INSTRUCTIONS" PRIOR TO COMPLETING THIS FORM.

Dates of Access Request*:

Through*

CO/ORG Point of Contact*:

Point of Contact Email Address*:

Contract #:

Point of Contact Telephone #*:

CAGE code:

THIS SECTION TO BE COMPLETED BY GOVERNMENT SPONSOR

Government Sponsor*:

Sponsor Organization*:

Purpose of Visit*:

Sponsor Telephone #*:

U.S. Passport or Resident Alien #*

DPTMS (RS) Form 21 Revised 05 Feb 2014

FOR OFFICIAL USE ONLY