Blank_Visit_Request.pdf

Full Name (LAST, First, Middle)

Place of Birth (City/State, or Country) Date of Birth (MM-DD-YYYY)

Dual Citizenship? YES NO If YES, List Countries

If YES, Immigrant Alien Number

Passport Number/Country Issued

Visa Type/Status

Position/Title

Security Clearance Level Clearance Granted by

Destination Organization Point(s) of Contact & Name of Escort (If Required) (Name, Office, Phone Number)

Office(s) to be Visited

Purpose of Visit

C4ISR Facility Visit Request Worksheet

Other Explanation

Date of Arrival Visit Expiration Date

DATA REQUIRED BY THE PRIVACY ACT (5 U.S.C. 522a) Authority under Executive Order 9397 for the purpose of ensuring positive identification. Use of the SSN is to ensure positive identification. Routine use is to obtain authorization for your visit to these facilities and access to classified information at the host organization. .Disclosure is voluntary; however,failure to provide the information may result in denial of access to host organization and access to classified information. Personnel requiring SCIF access must also provide a room number and office code for the individual or organization being visited.

SSN

Visitor's Organization

Mailing Address

City Zip Code

Country

Signature of Requestor (Sponsor): _______________________________________________________ Date

Clearance Verified Verified By __________________________________ Date

Date Verified By _________________________________________ Visit Verified SMS Updated Date

Approved Disapproved

Security Manager Phone Number

Visit Information (To be completed by visitor's sponsor - DO NOT include classified information on this form.)

Level of Access Granted

Current Nationality/Citizenship

Level of access required for this visit

Security Manager Use Only

State

Status

January 2011 - Previous editions obsolete

Worksheet Instructions

For non-C4ISR visitors all fields will be completed to ensure information required by the organization Security Manager is available to complete the visit approval process.

All foreign national visitors require all fields be completed.

For C4ISR assigned/attached U.S. military, C4ISR DoD employees, and C4ISR contractor personnel complete the following fields:

Name Position/Title Visitor's organization Name/telephone of Visitor's supervisor

Visit Information Section - all fields

Security Manager Only section - all fields

Dual Citizenship?

Please select only one.

C4ISR Facility Visit Request Worksheet DATA REQUIRED BY THE PRIVACY ACT (5 U.S.C. 522a) Authority under Executive Order 9397 for the purpose of ensuring positive identification. Use of the SSN is to ensure positive identification. Routine use is to obtain authorization for your visit to these facilities and access to classified information at the host organization. .Disclosure is voluntary; however,failure to provide the information may result in denial of access to host organization and access to classified information. Personnel requiring SCIF access must also provide a room number and office code for the individual or organization being visited.

Signature of Requestor (Sponsor): _______________________________________________________ Signature of authority requesting the visitor be granted access to the facilities identified on this form.

Verified By __________________________________ Verified By _________________________________________ Visit Information (To be completed by visitor's sponsor - DO NOT include classified information on this form.)

Security Manager Use Only January 2011 - Previous editions obsolete Page of Worksheet Instructions For non-C4ISR visitors all fields will be completed to ensure information required by the organization Security Manager is available to complete the visit approval process.

All foreign national visitors require all fields be completed.

For C4ISR assigned/attached U.S. military, C4ISR DoD employees, and C4ISR contractor personnel complete the following fields:

Name Position/Title Visitor's organization Name/telephone of Visitor's supervisor

Visit Information Section - all fields

Security Manager Only section - all fields

July 2010 APG C4ISR COE Facility Visit Request Form