US Citizens Security Access Form.pdf
PDF 132 KB Posted
- Attached to
- Chickamauga Lock Replacement Approach Wall and Decommissioning Federal contract opportunity
- Solicitation number
- W912P525T0AWD
About this file
This document is a U.S. Government security access form for U.S. citizens to request access to a project site for the Chickamauga Lock Replacement, Approach Walls and Decommissioning procurement.
The U.S. Army Corps of Engineers (USACE) Nashville District is planning a construction project for new downstream approach walls and decommissioning of the existing Chickamauga Lock in Chattanooga, Tennessee. The estimated project value is between $250-500 million. The scope includes construction of river and middle approach walls, decommissioning of the existing lock, wet commissioning of the new lock, and site restoration. USACE is conducting market research through one-on-one sessions with interested contractors and is requesting responses to a sources sought survey by November 11, 2024. Key information requested includes past performance, subcontracting approach, bonding capacity, and feedback on the potential use of a project labor agreement.
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| File | Type | Posted |
|---|---|---|
| Foreign National Secuirty Form.pdf |
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Text version
Version May 2023
COMPANY NAME / ADDRESS / MAIN PHONE #
Nashville District Corps of Engineers
Security Access Form
(US Citizens Only)
NOTE: At no time will a Contractor or Subcontractor Employee be permitted to access the site until approved by the Nashville District Security and the Organization POC has been notified in writing. Return forms to your USACE POC/Contract Rep for tracking.
Date Request is Being Submitted: (mm/dd/yyyy) _____________________
FULL 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.
Date of Birth (mm/dd/yyyy) ___________________ Social Security ___________________________
Place of Birth (City & State) __________________________________________________________
Citizenship (Country) _________________________________________
Project Office/ Work Site(s) where work is to be performed: __________________________
Start & End Date site access is needed ________________________________________________
Job Title _________________________________________________________________________
Primary Company POC Name and Phone # _____________________________________________
Primary Company POC Email Address: ________________________________________________
Note: Contractor shall furnish documentation to verify the employee is a U.S. Citizen if born outside the United States. Such documentation may include a U.S. passport (unexpired or expired), Certificate of U.S. Citizenship (INS Form N-560 or N-561), Certificate of Naturalization (INS Form N-550 or N-570) etc.
Contractor shall furnish two forms of ID listed on Form I-9 for US Citizens.
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.
For questions on the form question Nashville District Corps of Engineers Security Office:
*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
* Primary role for Personnel Security Investigations mailto:tracy.w.dorrough.civ@mail.mil mailto:john.h.carter@usace.army.mil mailto:jason.j.klinger.civ@mail.mil
| Social Security: |
| Citizenship Country: |
| Place of Birth City State: |
| Project Office Work Sites where work is to be performed: |
| Start End Date site access is needed: |
| Job Title: |
| Primary Company POC Name and Phone: |
| Primary Company POC Email Address: |
| Date of Birth (mm/dd/yyyy): |
| FULL Name: |
| Date Request is Being Submitted: (mm/dd/yyyy): |
| COMPANY NAME / ADDRESS / MAIN PHONE #: |
File details come from the government source that posted it. Updated .