US Citizen Pre-Bid or Site Visit Form MAR 2024_W912P524B0002_Obey River Sewer Phase II.pdf

Nashville District Corps of Engineers U.S. Citizen

Pre-Bid Meeting or Site Visit Request Form

This Request Form is for U.S. Citizens requesting approval to attend a pre-bid 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 Pre-Bid Meeting or Site Visit Point of Contact (POC) / Contracting Officer Representative (COR) to be forwarded to the LRN Security Management Office (LRN-SM) at least Five

(5) full business days prior to the proposed visit.

Guidance for submitting pre-bid meeting or site visit requests is available at https://www.lrd.usace.army.mil/Submit-ArticleCS/Programs/Article/3667149/contracting/

LRN Meeting/Site Visit POC: __________Andrew Roth_________________________ 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 _________________

LRN Field Location (Project Site) to be visited: ___Obey River Campground, 100 Obey Park Rd, Byrdstown, TN, 38573________

Date of Proposed Visit (mm/dd/yyyy) __06/13/2024__________________________

In Case of Questions, Please Provide Phone Number: __________________________

IMPORTANT: Submit form directly to COR. DO NOT submit the form directly to the Security Office Unless Directed. For questions regarding the site visit contact the COR.

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

Tracy Dorrough, Personnel Security Specialist, 615-736-7397 email: tracy.w.dorrough.civ@mail.mil John Carter, Security Specialist, 615-736-5567 email: john.h.carter@usace.army.mil Jay Klinger, District Chief of Security, 615-736-2185 email: jason.j.klinger.civ@mail.mil

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 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.

MAR 2024 Version

__________Andrew Roth___________________________________Andrew Roth_________________________

Solicitation W912P524B0002 Obey River Sewer Phase II https://www.lrd.usace.army.mil/Submit-ArticleCS/Programs/Article/3667149/contracting/ mailto:tracy.w.dorrough.civ@mail.mil mailto:john.h.carter@usace.army.mil mailto:jason.j.klinger.civ@mail.mil