US Citizen Pre-Bid or Site Visit Form JAN 19.pdf

01/23/2019

Nashville District Corps of Engineers

U.S. Citizen

Site Visit Request Form

This Request Form is for U.S. Citizens requesting approval to attend a meeting or site visit at one of the

Nashville District (LRN) Corps of Engineers field locations. The form should be submitted to the

Nashville District Meeting or Site Visit Point of Contact (POC) to be forwarded to the LRN Security

Management Office (LRN-SM) at least Five (5) full business days prior to the proposed visit.

LRN Meeting/Site Visit POC: _____________________________________

Nashville District (LRN) Contact Person)

Date the Request is Being Submitted to LRN (mm/dd/yyyy) ___________________

FULL LEGAL Name _______________________________________________________

(Last, First Middle)

If you have only initials in your name, use them and state (IO). If you have no middle name, enter

“NMN”. If you are a “Jr.,”Sr.,” “II,” etc., indicate your status (Do not list a Nickname)

NOTE: Failure to provide FULL LEGAL name will delay approval

Date of Birth (mm/dd/yyyy) ___________ Last Four Digits of Social Security Number ____________

Driver’s License Number and State ________________________

LRN Field Location (Project Site) to be visited: 1173 Carolina Ave NE, Cleveland, TN 37311

Date of Proposed Visit (mm/dd/yyyy) 06/30/2022

In Case of Questions, Please Provide Phone Number: __________________________

IMPORTANT: Submit form directly to Site Visit POC (contracting representative or Corps POC). DO

NOT submit the form directly to the Security Office Unless Directed. For questions regarding the site visit contact the Site Visit POC.

Only confirmed/approved visitors will be permitted on the tour. No substitutions or additions are allowed.

Visitors may not carry packages, backpacks, or other containers during the tour.

Photographs and video recording of the interior of the Power Plant is strictly prohibited.

No high-heel, open toe shoes, including clogs and Crocs or bare feet will be allowed on a tour.

NOTE: Any increase in threat conditions may result in an approved tour being cancelled with little notice. We regret any inconvenience this may cause.

For questions regarding completing the form, contact one of the individuals listed below:

Tracy Dorrough, Personnel Security Specialist, 615-736-7397 (Primary Security POC)

John Carter, Security Specialist, 615-736-7397

Jay Klinger, District Security Chief, 615-736-2185

PRIVACY ACT STATEMENT

AUTHORITY: Information is solicited pursuant to Title 10, U.S. Code, Section 3013 and E.O. 9397.

PRINCIPAL PURPOSE: To provide information necessary for preparation of a scheduled tour of the facility, verify positive identification of visitor(s), and conduct background checks for determinations of the eligibility of individuals for access to U.S.

Army Corps of Engineers facilities.

ROUTINE USES: Used by the U.S. Army Corps of Engineers to accompany a request for a scheduled tour of the facility.

MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT OF NOT PROVIDING INFORMATION: Providing the solicited information, including Social Security Number, is voluntary; however, failure to provide information may result in a denial of visitor access due to an inability to verify identification. The information provided to the U.S. Army Corps of

Engineers will not be retained digitally or by hard copy after the scheduled visit.

W912P522B0016 Mouse Creek 12th St Detention Structure Cleveland TN Tentatively Scheduled:

11:00AM Eastern, 30 Jun 2022 at 1173 Carolina Ave NE, Cleveland, TN 37311

Rob Holdsworth