Foreign_National_Security_Form.pdf

COMPANY NAME / ADDRESS / MAIN PHONE #

Nashville District Corps of Engineers Foreign National Security Form

NOTE: At no time will a Contractor or Subcontractor be permitted to access the site until approved by the Nashville District and the Contractor Official has been notified in writing.

All non-U.S. Citizens, including permanent residents who work on Nashville District (LRN) contracts or task orders shall be approved by the Headquarters U.S. Army Corps of Engineers (HQUSACE) Foreign Disclosure Officer (FDO) or higher before beginning work on the contract/task order.

Date Request is Being Submitted to the Security Office: (mm/dd/yyyy) ______________________________

FULL Name_______________________________________________________________________

(Last, First, Middle)

• If you have only initials in your name, use them and state (IO). If you have no middle name, enter “NMN”

• If you are a “Jr.,”Sr.,” “II,” etc., indicate your status

Date of Birth (mm/dd/yyyy): _________________ Citizenship (Country): ______________________

Passport # (Include copy scanned in color): _____________________________________________

Visa # (Include copy scanned in color if applicable): _______________________________________

* Visa information must be included unless country of citizenship is in the Visa Waiver Program

Work to be Performed:______________________________________________________________

Corps of Engineers Location (Project Office/ Work Site) Where Work is to be Performed:

From & To Dates for Requested Site Access: ____________________________________________

Expected Arrival Date: ___________________ Job Title: ___________________________________

Method of Payment (U.S. Dollars, Euros etc.): ___________________________________________

Primary Company POC Name/Phone: _________________________________________________

Primary Company POC Email Address: _______________________________________________

In addition to the information above, the Contractor shall furnish documentation to verify he/she was legally admitted into the United States and has an employment or immigrant Visa (unless in the Visa Waiver Program). This includes, individuals living and working in the United States but are not U.S. Citizens, such as permanent residents.

In addition to the requirements above, all non-U.S. Citizens who have lived in the United States for at least three years must also have or obtain a favorable background investigation in accordance with Homeland Security Presidential Directive 12 (HSPD-12) (guidance provided separately).

Nashville District Corps of Engineers Security Office Contact Information:

Tracy Dorrough, Security Technician, 615-73-7397 email: tracy.dorrough@usace.army.mil Jay Klinger, Security Specialist, 615-736-2185 email: jason.j.klinger@usace.army.mil Connie Hardeman, Security Manager, 615-736-5567 email: connie.f.hardeman@usace.army.mil