Visitor_Access_Form_-_Navy.pdf

Name:

(First, MI, Last) SSN Driver Lic # Address City State Zip Code DOB POB

Organization

Bldg #

Contract

Exp Date

Results

A/P/D

Contractor POC Name:

Email/phone:

To support the Department of the Army physical security and access control program; Information Assurance Program; to record personal data that is used in support of

DTM 09-12; to provide a record of security/access badges issued; to restrict entry to installations and activities; to ensure positive identificaiton of personnel authorized access; to maintain accountability for issuance and dispostition of security/access badges.

Mandatory. Failure to provide this information will result in the applicant not being able to gain access to Fort Detrick.

PRINCIPAL PURPOSE:

DISCLOSURE:

ROUTINE USES:

FORT DETRICK NON-DOD AND NON-FEDERAL

EMPLOYEE VISITOR'S VETTING AND BADGE FORM

ORGANIZATION: NMRC-Frederick, Bldg 8400

AUTHORITY:

PRIVACY ACT STATEMENT

10 U.S.C. 3013, Secretary of the Army; Army Regulation 190-13, The Army Physical Security Program.

Date:

Used by the Provost Marshall's Office to vet all Non-DOD and Non-Federal Employee visitors to Fort Detrick.

Form can be hand delivered to building 1520 or emailed to: USARMY.DETRICK.USAG.MBX.DES-VETTING@MAIL.MIL

Phone: 301-619-1191/4580 FAX: 301-619-0750 (Results =Approved "A"/Pending "P"/Disapproved "D" Email to:FACILITY MANAGER, NMRC-FREDERICK, BLDG 8400

Requestor (P) Name:

Authorizing Officer's Signature:

David M. Wolfe, Ph.D.

LT, MSC, USN

Security Manager NMRC-Frederick

8400 Research Plaza, Ft Detrick, MD 21702 robert.j.franciscovich.civ@mail.mil 240-478-8767(BB)/301-619-1570 (O)

X R o b e r t J . F r a n c i s c o v i c h

F a c i l t i y M a n a g e r , N M R C - F r e d e r i c k

Fort Detrick From 190-13a November 2011 FD V1.00 mailto:robert.j.franciscovich.civ@mail.mil