US Citizens Security Access Form.pdf
PDF 132 KB Posted
- Attached to
- Virtual Industry Day - Chickamauga Lock Replacement Approach Wall and Decommissioning Federal contract opportunity
- Solicitation number
- Not on record
About this file
This is a Security Access Form for U.S. citizens seeking to access Nashville District Corps of Engineers facilities, specifically for the Chickamauga Lock Replacement virtual industry day. The form requires personal information including full legal name, date of birth, social security number, place of birth, citizenship, project work site details, job title, and company point of contact information.
The form outlines specific documentation requirements for U.S. citizens born outside the United States, including acceptable forms of proof like U.S. passports, Certificates of U.S. Citizenship (INS Form N-560 or N-561), or Certificates of Naturalization (INS Form N-550 or N-570). Two forms of identification listed on Form I-9 are required for all U.S. citizens. The form emphasizes that no contractor or subcontractor employee will be granted site access until approved by Nashville District Security and written notification is provided to the Organization POC. The form includes contact information for three security office personnel who can address questions about the form.
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| File | Type | Posted |
|---|---|---|
| FN Contractor Sec Access 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 .