US Citizens Security Access Form.pdf
PDF 186 KB Posted
- Solicitation number
- W912P527QA001
About this file
This is a Security Access Form issued by the Nashville District Corps of Engineers for contractor and subcontractor employee site access. The form is restricted to U.S. citizens only and must be submitted prior to any employee being permitted to access the facility. No contractor or subcontractor employee may access the site until approved by the Nashville District and the Contractor Official has been notified in writing.
The form requires the submission of the employee's full name (including any suffixes), date of birth, Social Security number, place of birth, citizenship country, project office/work site location, site access start and end dates, job title, and primary company point of contact information. Contractors must furnish documentation verifying U.S. citizenship for employees born outside the United States, such as a U.S. passport, Certificate of U.S. Citizenship (INS Form N-560 or N-561), or Certificate of Naturalization (INS Form N-550 or N-570). Additionally, contractors must provide two forms of identification listed on Form I-9 for U.S. citizens. Information is collected pursuant to Title 10, U.S. Code, Section 3013 and Executive Order 9397 for facility tour preparation, positive identification verification, and background checks to determine access eligibility. While providing solicited information, including Social Security numbers, is voluntary, failure to provide such information may result in access denial. The information will not be retained digitally or in hard copy after the scheduled visit. The Nashville District Corps of Engineers Security Office can be contacted at 615-736-7397 (Mr. Dorrough, Personnel Security Specialist) or 615-736-2185 (Mr. Klinger, District Chief of Security).
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Other files
| File | Type | Posted |
|---|---|---|
| FN Contractor Sec Access Form.pdf | ||
| Solicitation Amendment W912P527QA0010001 SF 30.pdf | ||
| Solicitation - W912P527QA001.pdf |
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Text version
Version March 2025
COMPANY NAME / ADDRESS / MAIN PHONE #
Nashville District Corps of Engineers
Security Access Form
(US Citizens Only)
NOTE: At no time will a Contractor or Subcontractor Employee be permitted to access the site until approved by the Nashville District and the Contractor Official has been notified in writing.
Date Request is Being Submitted: (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) ___________________ Social Security ___________________________
Place of Birth (City & State) __________________________________________________________
Citizenship (Country) _________________________________________
Project Office/ Work Site(s) where work is to be performed: __________________________
Start & End Date site access is needed ________________________________________________
Job Title _________________________________________________________________________
Primary Company POC Name and Phone # _____________________________________________
Primary Company POC Email Address: ________________________________________________
Note: Contractor shall furnish documentation to verify the employee is a U.S. Citizen if born outside the United States. Such documentation may include a U.S. passport (unexpired or expired), Certificate of U.S. Citizenship (INS Form N-560 or N-561), Certificate of Naturalization (INS Form N-550 or N-570) etc.
Contractor shall furnish two forms of ID listed on Form I-9 for US Citizens.
PRIVACY ACT STATEMENT
AUTHORITY: Information is solicited pursuant to Title 10, U.S. Code, Section 3013 and E.O. 9397.
PRINCIPAL PURPOSE: To provide information necessary for preparation of a scheduled tour of the facility, verify positive identification of visitor(s), and conduct background checks for determinations of the eligibility of access to U.S. Army Corps of Engineers facilities.
ROUTINE USES: Used by the U.S. Army Corps of Engineers to accompany a request for a scheduled tour of the facility.
MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT OF NOT PROVIDING INFORMATION: Providing the solicited information, including Social Security Number, is voluntary; however, failure to provide information may result in a denial of visitor access due to an inability to verify identification. The information provided to the U.S. Army Corps of Engineers will not be retained digitally or by hard copy after the scheduled visit.
Nashville District Corps of Engineers Security Office Contact Information:
* Mr. Dorrough, Personnel Security Specialist, 615-736-7397 email: tracy.w.dorrough@usace.army.mil
Mr. Klinger, District Chief of Security, 615-736-2185 email: jason.j.klinger@usace.army.mil
* Primary - Personnel Security Investigations mailto:tracy.w.dorrough@usace.army.mil mailto:jason.j.klinger.civ@mail.mil
| Job Title: |
| Date of submission: |
| Full Legal Name: |
| Date of Birth: |
| Social Security Number: |
| City and State you were born in: |
| Project or site you are working at: |
| Country of Citizenship: |
| Company you work for: |
| Date you start and finish the job: |
| Your companies POC Email Address: |
| The name of your Companies POC: |
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