Attachment_0004_-_Visistor_Request_Form.pdf

FOR OFFICIAL USE ONLY

VISITOR NOTIFICATION/TEMPORARY SECURITY IDENTIFICATION BADGE

U.S. Army Watervliet Arsenal

Governing Directive is AR 190-13 Questions about completing this form? call 518-266-5297 / 4338 or DSN 374-5297 / 4338

GOVERNMENT/ARSENAL PARTNERSHIP SPONSOR(S) - ALL VISITORS REQUIRE A SPONSOR

Primary POC: Alternate POC:

Name: Name:

Phone #: Phone #:

Office: Office:

Provide two Points of Contact (POC) with different phone numbers OR provide an office number AND cell phone number so we can contact you if necessary. Upon completion of form, send to james.r.osgood2.civ@mail.mil encrypted, Partnership requests are to be sent to usarmy.watervliet.tacom.mbx.secure-noticeofvisit@mail.mil. Benet Laboratories' requests should be sent to usarmy.watervliet.rdecom.list.bene-wsb-visit@mail.mil.

Beginning Date

DATE(S) OF VISIT

DD Month YYYY End Date:

Purpose (Include Destination - Mandatory):

VISITOR NAME:

LAST, FIRST MI (JR/SR)

*Foreign National? G2

Approved

**DoD Employee Legal

Approved

DOB

MM/DD/YYYY

GOVERNMENT ID #

Name: ID Number

Business Name or Govt Organization Issuing Authority / Exp. Date:

Name: ID Number

Business Name or Govt Organization Issuing Authority / Exp. Date:

Name: ID Number

Business Name or Govt Organization Issuing Authority / Exp. Date:

* FOREIGN NATIONAL VISITS (NON-US CITIZEN VISITORS)

If your visitor is a Foreign National you MUST coordinate the visit with the Intelligence & Security Office (I&S). Failure to do so will result in your visitor being denied entrance to the installation. **Please mark in the “FN” column with “Y” (yes) and “N” (no) indicating whether your visitor is a Foreign National AND if the G-2 office approved the visit. YOU are responsible for escorting a Foreign National visitor at ALL TIMES. Escorts must be listed on page 2.

** PAST & PRESENT DOD EMPLOYEES, INCLUDING RESERVES & GUARD

Sponsors of past/present DoD employees, including Reserves and National Guard, who are seeking to conduct commercial activities with the government, must obtain verification/authorization from the WVA Legal Office indicating there are no restrictive conflicts of interest. Once the indiviual has been cleared by the Legal Office the WVA Form 190-8 can then be submitted to the Visitor Control Center (VCC).

FOR VISITOR CONTROL PURPOSES ONLY - PROCESSING AND APPROVAL

VCC ASSOCIATE: Indicate completion of name check by NCIC by initialing to the left of the individuals name above. If no derogatory information is on file, approve visit request/badge application. File NCIC transaction record alphabetically for each day. Send copy of approved visit request/badge applicaiton to government sponsor/POC listed on form. If derogatory information is obtained, notify Intelligence & Security Office (I&S) for processing requirements.

APPROVED ADDITIONAL PROCESSING REQUIRED

Remarks:

NOTE: Do not electronically sign form until all data has been entered. Electronic signature will lock the form and prevent changes from being made.

Signature:

Date: (DD MMM YYYY)

WVA FORM 190-8, 10 May 2017 replaces May 2015 FOR OFFICIAL USE ONLY Page 1 of 3

* If yes, ** If yes, (Driver's License, State Issued ID, etc.)

mailto:james.r.osgood2.civ@mail.mil mailto:usarmy.watervliet.tacom.mbx.secure-noticeofvisit@mail.mil mailto:usarmy.watervliet.rdecom.list.bene-wsb-visit@mail.mil

ADDITIONAL VISITORS

Name: ID Number

Business Name or Govt Organization Issuing Authority / Exp. Date:

Name: ID Number

Business Name or Govt Organization Issuing Authority / Exp. Date:

Name: ID Number

Business Name or Govt Organization Issuing Authority / Exp. Date:

Name: ID Number

Business Name or Govt Organization Issuing Authority / Exp. Date:

Name: ID Number

Business Name or Govt Organization Issuing Authority / Exp. Date:

Name: ID Number

Business Name or Govt Organization Issuing Authority / Exp. Date:

Name: ID Number

Business Name or Govt Organization Issuing Authority / Exp. Date:

Name: ID Number

Business Name or Govt Organization Issuing Authority / Exp. Date:

ESCORTS FOR FOREIGN NATIONAL VISITORS

NAME: LAST, FIRST MI (JR/SR) E-MAIL PHONE # DATE

WVA FORM 190-8, 10 May 2017 replaces May 2015 FOR OFFICIAL USE ONLY Page 2 of 3

VISITOR NAME:

LAST, FIRST MI (JR/SR)

*Foreign National? G2

Approved

**DoD Employee Legal

Approved

DOB

MM/DD/YYYY

GOVERNMENT ID #

* If yes, ** If yes, (Driver's License, State Issued ID, etc.)

VISITOR NOTIFICATION/TEMPORARY SECURITY IDENTIFICATION BADGE

U.S. Army Watervliet Arsenal

Governing Directive is AR 190-13

PRIVACY ACT STATEMENT

AUTHORITY: 5 USC Section 301

PRINCIPAL PURPOSE(S): To provide a means for issuing security badges and/or visitor pass on the installation.

ROUTINE USE(S): None. “Blanket Routine Uses” set forthe at the beginning of the Army’s Complilation of Systems of Record Notices also applies to this system.

DISCLOSURE: Voluntary. However, failure to provide all the required information may result in denial of access to the installation.

IMPORTANT NOTE: It is your responsibility to give the Visitor Control Center (VCC) advanced notice of the pending visits to avoid delays in the in-processing of your visitors.

SPONSORSHIP INSTRUCTIONS:

1. For visit authorization e-mail the completed form to james.r.osgood2.civ@mail.mil. The request must be received 24 hours prior to visit for approval.

FOREIGN NATIONAL/NON-US CITIZEN VISIT:

1. For visit authorization send the completed form to WVA Security & Intelligence (I&S). The request must be received seven (7) business days prior to the visit for approval.

DATE(S) OF VISIT: Please provide beginning and ending dates for the meeting/visit. In the “Purpose” section please provide the reason for the request.

Seeking to fo Commercial Activities with the Government?

1. Past and present DoD employees, including Reserves/National Guard seeking to conduct commercial activities with the government must obtain a visit authorization from the WVA Legal Office.

2. Your request must be received seven (7) business days prior to the visit by the Legal Office for authorization. The Legal Office will return the form to you for further coordination with the VCC.

3. Send the completed WVA Form 190-8 with authorization from the Legal Office to:

WVA FORM 190-8, 10 May 2017 replaces May 2015 FOR OFFICIAL USE ONLY Page 3 of 3 mailto:james.r.osgood2.civ@mail.mil