FRCSE_VISITOR_ACCESS_FORM_10-15.pdf

Please wait...

If this message is not eventually replaced by the proper contents of the document, your PDF viewer may not be able to display this type of document.

You can upgrade to the latest version of Adobe Reader for Windows®, Mac, or Linux® by visiting http://www.adobe.com/go/reader_download.

For more assistance with Adobe Reader visit http://www.adobe.com/go/acrreader.

Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries. Mac is a trademark of Apple Inc., registered in the United States and other countries. Linux is the registered trademark of Linus Torvalds in the U.S. and other countries.

FRCSEINST 5500.5

All fields are required Complete all required fields and mark unused optional fields with N/A.

FRCSE VISIT ACCESS/BADGE REQUEST

(THIS FORM IS FOR U.S. CITIZENS ONLY)

FRCSE 5500/17 (Rev. 10-21-15) Adobe LiveCycle Designer (electronic) Adobe LiveCycle Designer (printed)

PRIVACY ACT ADVISEMENT

AUTHORITY: 5 U.S.C. 522a, Privacy Act of 1974. PRINCIPLE PURPOSE: to readily identify all personnel who are allowed to access Naval Air Station Jacksonville and the FRCSE in the furtherance of the Center's Mission; and to comply, verify and update the Center authorized visitor list in support of administrative and security measures. Disclosure is VOLUNTARY. Furnishing personal information on this form including your social security number is totally voluntary, but failure to do so may result in disapproval of NAS Jacksonville and FRCSE entry.

PLEASE ALLOW AT LEAST FIVE (5) WORKING DAYS FOR PROCESSING

11. DOES VISITOR

HAVE ACCESS

TO NAS JAX?

1. VISITOR NAME (print or type) Visitor

9. VISIT LOCATION

VISITOR INFORMATION (AS IT APPEARS ON CURRENT GOV'T ISSUED IDENTIFICATION TO BE PRESENTED FOR BASE ACCESS/ADDITIONALLY THE VISITOR MUST PROVIDE THIS NUMBER, 790-5500, TO THE NAS PASS AND ID OFFICE UPON ARRIVAL).

Visitor

SECTION I - VISITOR INFORMATION

2. STATUS

Visitor Visitor

4. COMPANY TYPE

Visitor CERTIFYING OFFICIAL (A company official will verify the visit request and certify the clearance and access information is true and correct, including US citizenship, and that contact has been made with the FRCSE point of contact, relative to this visit. Individuals will not certify themselves. The certifying company official will be the Security Officer or a VP or above within the visitor's company.)

SECTION II - CERTIFYING OFFICIAL

DO NOT email this form using the email button unless all blocks in section III are completed.

SECTION III - FRCSE POINTS OF CONTACT/SPONSORS (TWO ARE REQUIRED)

NOTE: FRCSE POC/SPONSOR AS A GENERAL GUIDELINE YOU CAN EXPECT THE VISITOR TO RECEIVE ONE OF THE FOLLOWING TYPES OF ACCESS CONTROL BADGES:

a. PROXIMITY (ELECTRONICALLY OPENS TURNSTILES/GATES, USUALLY ISSUED FOR PERIODS GREATER THAN 30 DAYS NOT TO EXCEED 1 YEAR).

b. NON-PROXIMITY (WILL NOT PROVIDE ELECTRONIC ACCESS) NO ESCORT REQUIRED (GREEN) (NO ESCORT IS REQUIRED/1-30 DAY VISITS).

Sponsor submits all requests to:

1d. TYPE Visitor 2d. TYPE Visitor 9.0.0.2.20120627.2.874785