Visitor_Request_form1246R_Mar-2017.pdf

FOR OFFICIAL USE ONLY

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 USC Section 301; Title 5 USC Section 2951

PRINCIPAL PURPOSE: To provide commanders and law enforcement officials with means by which information may be accurately identified.

ROUTINE USES: Your social security number is used as an additional/alternate means of identification to facilitate filing and retrieval.

DISCLOSURE: Disclosure of your social security number is voluntary, however, failure to provide the information requested may delay or prevent approval of your request.

AKA:

GRADE/RANK:

DATE/TIME OF DEPARTURE:

STATE:

PLACE OF BIRTH:

SEX:

HAIR COLOR:

HEIGHT:

HOME PHONE NUMBER:

POC PHONE:

NAME:

SSN:

ORGANIZATION:

HOME ADDRESS:

PURPOSE OF VISIT:

AREA(S) TO BE VISITED:

DATE/TIME OF ARRIVAL:

DRIVERS LICENSE #:

DATE OF BIRTH:

CITIZENSHIP:

EYE COLOR:

WEIGHT:

WORK PHONE NUMBER:

POC AT SIERRA:

Reason Camera Is Required:

LE Division NCIC Check – Escort Required?

Date:

Security Manager/Physical Security Specialist Approval:

Entry Granted: Yes No

SIAD Form 1246R, MAR 2017 ALL PREVIOUS EDITIONS ARE OBSOLETE

FOR OFFICIAL USE ONLY

No Escort Req. Escort Req. No Driving Denied

Name of NCIC Operator: