US Citizens Security Access Form.pdf
PDF 132 KB Posted
- Attached to
- Chickamauga Lock Replacement Approach Wall and Decommissioning Federal contract opportunity
- Solicitation number
- W912P525RA001
About this file
This is a Security Access Form for US citizens requesting access to Nashville District Corps of Engineers facilities, specifically related to the Chickamauga Lock Replacement Project solicitation W912P525RA001. The form is required for contractors and subcontractors to gain site access approval from Nashville District Security.
The form requires detailed personal information including full legal name, date of birth, social security number, place of birth, citizenship status, work site location, access dates needed, job title, and company POC details. For individuals born outside the US, additional documentation such as US passport, Certificate of Citizenship (INS Form N-560/N-561), or Certificate of Naturalization (INS Form N-550/N-570) must be provided to verify US citizenship. The form must be submitted to the USACE POC/Contract Representative and approved by security before any site access is granted. Three security office contacts are provided for questions: Tracy Dorrough (Personnel Security Specialist), John Carter (Security Specialist), and Jay Klinger (District Chief of Security).
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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 .