Attachment_0005_APG_Visitor_Request_Form_5207-E.pdf

CECOM FORM 5207-E, AUG 2014 PREVIOUS EDITIONS ARE OBSOLETE

C4ISR VISIT REQUEST

(See instructions on next page before completion.)

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.

VISITOR INFORMATION

1. Visitor Type: 2. Other (Required if Other is specified as Visitor Type):

3. Full Name (Last, First, Middle): 4. Country of Citizenship (Enter country if not listed):

5. DOD EDIPI (Required if visitor has a CAC): 6. Date of Birth (YYYYMMDD) (Required if visitor has a CAC):

7. SSN (Required if visitor is US Citizen, but does not have a CAC): 8. Dual Citizenship?

a. Yes No

b. If Yes, List Countries:

9. Immigrant Alien Number: 10. Visa Type/Status:

11. Passport Number/Country Issued:

12. Visitor's Organization:

13. Country (Enter Country if not listed): 14. Position/Title:

15. Security Clearance Level: 16. Other (Required if Other is specified as Security Clearance Level):

VISIT INFORMATION

(To be completed by visitor's sponsor. DO NOT include classified information on this worksheet.)

17. Visit Type: 18. Location (Select from drop-down list or enter directly):

19. Organization(s) to visit (Select from drop-down or enter directly): 20. Sub-Organization(s):

21. Purpose of Visit:

22. Arrival Date

(YYYYMMDD):

23. Arrival Time:

24. Departure Date

(YYYYMMDD):

25. Departure Time:

26. Primary POC/Escort:

a. Name: b. Organization: c. Phone:

d. Signature: e. Date:

SECURITY MANAGER USE ONLY

27. Clearance and Level of Access Verified?

Approved Disapproved

b. Verified By: c. Phone: d. Date:

28. JPAS/SPAN Verified?

a.

a. Verified By: b. Phone: c. Date:

FOR OFFICIAL USE ONLY

CECOM FORM 5207-E, AUG 2014 PREVIOUS EDITIONS ARE OBSOLETE

INSTRUCTIONS FOR COMPLETION OF

C4ISR VISIT REQUEST

BLOCK 1. Visitor Type: Select from the following choices:

C4ISR Military, DOD Employee, Contractor, US Military, US Govt, Foreign National, Other. If Other is selected, you must fill in Block 2.

BLOCK 2. Other: If you selected "Other" in Block 1, enter your Visitor Type (e.g. Non-DOD Civilian).

BLOCK 3. Full Name: Last Name, First Name, Middle Initial.

BLOCK 4. Country of Citizenship: Select or enter your Country of Citizenship.

BLOCK 5. DOD EDIPI: Enter your DOD Electronic Data Interchange Personal Identifier (EDIPI). This unique ID number can be found on the back of your Common Access Card (CAC). This is a required field for all visitors with a

CAC.

BLOCK 6. Date of Birth: Enter your Date of Birth (YYYYMDD). This is a required field for all visitors with a

CAC.

BLOCK 7. SSN: Social Security Number is a required field for all US Citizens that do not have a Common Access Card

(CAC).

BLOCK 8. Dual Citizenship:

a. Check the box that applies.

b. List countries of citizenship, if applicable.

BLOCK 9. Immigrant Alien Number: This is a required field if you are not a U.S. Citizen.

BLOCK 10. Visa Type/Status: This is a required field if you are not a U.S. Citizen.

BLOCK 11. Passport Number/Country Issued: This is a required field if you not a U.S. Citizen. Enter "Pending" if your passport application is in process.

BLOCK 12. Visitor's Organization: Name of your organization/company.

BLOCK 13.: Country: Select or enter the country in which your organization/company is located.

BLOCK 14. Position/Title: Enter your position and/or title.

BLOCK 15. Security Clearance Level: Select your clearance level from the following choices: Confidential, Secret, Top Secret, TS/SCI, None, Other. If Other is selected, you must fill in Block 16.

BLOCK 16. Other: If you selected "Other" in Block 13, enter your Security Clearance Level information.

BLOCK 17. Visit Type: Categorize your visit as Unclassified or Classified.

BLOCK 18. Location: Select the location of your visit from the following choices: Aberdeen Proving Ground, Fort Belvoir, Fort Huachuca, Tobyhanna Army Depot. You may also enter text directly into this field if your location is not listed or you are visiting multiple locations.

BLOCK 19. Organization(s) to visit: Select the Organization you will visit from the following choices: ACC, ARI, ARL, DLA, CECOM, CERDEC, PEO C3T, PEO EIS, PEO IEWS, PEO SoSE&I. You may also enter text directly into this field if the organization you are visiting is not listed or you are visiting multiple organizations. Your visit is limited by organization, so please list all organizations you plan to visit.

BLOCK 20. Sub-Organization(s): Enter the names of the sub-organizations you plan to visit.

BLOCK 21. Purpose of Visit: Enter the reason for your visit. Include location(s) and building(s) you are visiting along with the reason.

BLOCKS 22/23. Arrival Date and Time: Enter the date and time that you expect to arrive.

BLOCKS 24/25. Departure Date and Time. Enter the date and time you expect to leave.

BLOCK 26. Primary POC/Escort:

a. Name of Primary POC/Escort.

b. Organization of Primary POC/Escort.

c. Phone number of Primary POC/Escort.

d. Signature of person filling out and submitting the form.

e. The date will be automatically set when signed.

BLOCK 27. Clearance Level of Access Verified?:

a. Access approved or disapproved by Security Manager.

b. Signature of Security Manager who verified access.

c. Phone number of Security Manager who verified access.

d. The date will be automatically set when signed.

BLOCK 28. JPAS/SPAN Verified?:

a. The signature of the Security Manager who verified the security clearance/access in the Joint Personnel Adjudication System (JPAS) or the Security Policy Automation Network (SPAN) for approved foreign visits.

b. Phone number of the Security Manager who verified the security clearance/access or foreign visit.

c. The date will be automatically set when signed.

CECOM FORM 5207-E, AUG 2014

PREVIOUS EDITIONS ARE OBSOLETE

9.0.0.2.20101008.1.734229

C4ISR VISIT REQUEST

(See instructions on next page before completion.)

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.

VISITOR INFORMATION

8. Dual Citizenship?

a.

VISIT INFORMATION

(To be completed by visitor's sponsor. DO NOT include classified information on this worksheet.)

26. Primary POC/Escort:

SECURITY MANAGER USE ONLY

27. Clearance and Level of Access Verified?

28. JPAS/SPAN Verified?

a.

FOR OFFICIAL USE ONLY

INSTRUCTIONS FOR COMPLETION OF

C4ISR VISIT REQUEST

BLOCK 1. Visitor Type: Select from the following choices: C4ISR Military, DOD Employee, Contractor, US Military, US Govt, Foreign National, Other. If Other is selected, you must fill in Block 2.

BLOCK 2. Other: If you selected "Other" in Block 1, enter your Visitor Type (e.g. Non-DOD Civilian).

BLOCK 3. Full Name: Last Name, First Name, Middle Initial.

BLOCK 4. Country of Citizenship: Select or enter your Country of Citizenship.

BLOCK 5. DOD EDIPI: Enter your DOD Electronic Data Interchange Personal Identifier (EDIPI). This unique ID number can be found on the back of your Common Access Card (CAC). This is a required field for all visitors with a CAC.

BLOCK 6. Date of Birth: Enter your Date of Birth (YYYYMDD). This is a required field for all visitors with a CAC.

BLOCK 7. SSN: Social Security Number is a required field for all US Citizens that do not have a Common Access Card (CAC).

BLOCK 8. Dual Citizenship:

a. Check the box that applies.

b. List countries of citizenship, if applicable.

BLOCK 9. Immigrant Alien Number: This is a required field if you are not a U.S. Citizen.

BLOCK 10. Visa Type/Status: This is a required field if you are not a U.S. Citizen.

BLOCK 11. Passport Number/Country Issued: This is a required field if you not a U.S. Citizen. Enter "Pending" if your passport application is in process.

BLOCK 12. Visitor's Organization: Name of your organization/company.

BLOCK 13.: Country: Select or enter the country in which your organization/company is located.

BLOCK 14. Position/Title: Enter your position and/or title.

BLOCK 15. Security Clearance Level: Select your clearance level from the following choices: Confidential, Secret, Top Secret, TS/SCI, None, Other. If Other is selected, you must fill in Block 16.

BLOCK 16. Other: If you selected "Other" in Block 13, enter your Security Clearance Level information.

BLOCK 17. Visit Type: Categorize your visit as Unclassified or Classified.

BLOCK 18. Location: Select the location of your visit from the following choices: Aberdeen Proving Ground, Fort Belvoir, Fort Huachuca, Tobyhanna Army Depot. You may also enter text directly into this field if your location is not listed or you are visiting multiple locations.

BLOCK 19. Organization(s) to visit: Select the Organization you will visit from the following choices: ACC, ARI, ARL, DLA, CECOM, CERDEC, PEO C3T, PEO EIS, PEO IEWS, PEO SoSE&I. You may also enter text directly into this field if the organization you are visiting is not listed or you are visiting multiple organizations. Your visit is limited by organization, so please list all organizations you plan to visit.

BLOCK 20. Sub-Organization(s): Enter the names of the sub-organizations you plan to visit.

BLOCK 21. Purpose of Visit: Enter the reason for your visit. Include location(s) and building(s) you are visiting along with the reason.

BLOCKS 22/23. Arrival Date and Time: Enter the date and time that you expect to arrive.

BLOCKS 24/25. Departure Date and Time. Enter the date and time you expect to leave.

BLOCK 26. Primary POC/Escort:

a. Name of Primary POC/Escort.

b. Organization of Primary POC/Escort.

c. Phone number of Primary POC/Escort.

d. Signature of person filling out and submitting the form.

e. The date will be automatically set when signed.

BLOCK 27. Clearance Level of Access Verified?:

a. Access approved or disapproved by Security Manager.

b. Signature of Security Manager who verified access.

c. Phone number of Security Manager who verified access.

d. The date will be automatically set when signed.

BLOCK 28. JPAS/SPAN Verified?:

a. The signature of the Security Manager who verified the security clearance/access in the Joint Personnel Adjudication System (JPAS) or the Security Policy Automation Network (SPAN) for approved foreign visits.

b. Phone number of the Security Manager who verified the security clearance/access or foreign visit.

c. The date will be automatically set when signed.