NSSC_Contractor_Request_Form.pdf

FO

U

O

In c om pl ia nc e w ith th e Pr iv ac y Ac t o f 1

4, th is in fo rm at io n is Pe rs on al D at a an d m us t b e pr ot ec te d fr om d is cl os ur e.

N

SS

C C on tr ac to r A cc es s R eq ue st

F or m

C om pa ny N am e:

B ld g/ A re a w or ki ng

N

SS

C P

O C

PO

P ho ne

L as t N am e Fi rs t N am e

D

B

D L

L

St at e C ur re nt A dd re ss

St es R es id ed in g Pa st

Y ea rs

Pe r U

.S . A rm y

D ire ct iv e- Ty pe M em or an du m (D

TM

) 0

9-

2, a ll of th e ab ov e in fo rm at io n is re qu ire d fo r u ne sc or te d ac ce ss

If th e

PO

C o r vi si to r e le ct s n ot to p ro vi de a ll th e in fo rm at io n re qu es te d, th en th e vi si to r m us t b e si gn ed in a t t he g at e by th e

PO

C a nd e sc or te d th e en tir e tim e th ey a re o n th e in st al la tio n.

T he

P O

C w ill o nl y be n ot ifi ed if th e vi si to r i s n ot a ut ho riz ed e nt ry o nt o th e in st al la tio n.

A ll

U .S

. v is ito rs ye ar s o f a ge a nd o ld er m us t b e ve tte d pr io r t o en try to

N

SS

C

Fo re ig n vi si to rs

(b ot h of fic ia l a nd u no ff ic ia l) m us t b e ve tte d th ro ug h th e ap pr op ria te

F or ei gn

D is cl os ur e

O ff ic er b as ed o n th e or ga ni za tio n he

/s he is c om in g to se e.

P le as e co nt ac t t he a pp ro pr ia te of fic e fo r i ns tru ct io ns

. F or

N

SR

D

EC

/T A

C O

M c on ta ct

-2

-5 an d fo r a ll ot he rs c on ta ct

D

PT

M S at

-2

-6

2.

c om pl ia nc e w ith th e Pr iv ac y Ac t o f 1

4, th is in fo rm at io n is Pe rs on al D at a an d m us t b e pr ot ec te d fr om d is cl os

To p ro te ct P

II

, t he re a re tw o m et ho ds o f s ub m itt in g th is fo rm . T hi s f or m c an b e em ai le d en cr yp te d to

U

SA

R

M Y

N at ic k

SS

C

IM

C

M tla nt ic L is t N

A

TI

-P ol ic eV is ito rA cc es s” a t e m ai l a dd re ss u sa rm y.

na tic k.

im co m

-a tla nt ic

.li st

.n at i-p ol ic ev is ito ra cc es s@ m ai l.m il.

lte rn at iv el y, th is fo rm c an b e fa xe d to (5

) 2

-6

3.

R eq ue st s m us t b e re ce iv ed b y

U

SA

G N at ic k Po lic e at le as t 2 ho ur s p rio r t o th e vi si to r’ s a rr iv al

U po n su cc es sf ul v et tin g, th e vi si to r w ill be a dd ed to th e D ai ly

A cc es s R os te r f or th e da te o f t he v is it.

T he

D ai ly A cc es s R os te r i s m ai nt ai ne d at th e M ai n

G

If a v is ito r h as a lre ad y be en v et te d w ith in th e la st da ys

, t he n se nd a n em ai l r eq ue st to th e ab ov e ad dr es s a t l ea st ho ur s p rio r t o th e vi si to r’ s a rr iv al

. I nc lu de th e vi si to r’ s f ul l n am e, d at e of v is it, ti m e of v is it an d

PO

C

If th e vi si to r w as v et te d w ith in th e la st da ys , t he y w ill b e ad de d to th e

D ai ly A cc es s R os te r.

V is ito rs n ot v et te d w ith in th e la st da ys w ill h av e to re su bm it th is fo rm to th e

U

SA

G N at ic k Po lic on ta ct th e U

SA

G

N at ic k

Po lic e D es k at

-2

-4

1, to v er ify w he th er o r n ot a v is ito r h as b ee n ve tte d w ith in th e la st da ys

Pl ea se d ire ct a ny q ue st io ns re ga rd in g th is p ro ce ss to th e

U

SA

G N at ic k Po lic e

D es k at

-2

-4 or

R ic k D ut ki ew ic z at

-2

-4

9.