Devens_Visitors_Pass_Request_Upated_4_APR_2023.pdf
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- Attached to
- Design Bid Build Construction of a Collective Enlisted Training Barracks at Devens RFTA, MA
- Solicitation number
- W912QR26RA051
About this file
This is a Fort Devens Access Control Visitors Pass request form used by the Installation Access Control Office to process visitor access to the Fort Devens military installation. The form collects applicant information including name, Social Security number, driver's license details, citizenship status, felony conviction history, and sex offender registration status. Applicants must specify their reason for visit, which includes options for non-DoD contractors/vendors, foreign nationals, training/appointments, family care providers, drill/muster, or other purposes. The form requires designation of the building number to be visited, the point of contact name and phone number, and the number of requested visit days (01-30 days maximum).
Applicants must certify their understanding of Fort Devens Police background screening requirements, acknowledge that access may be revoked at any time without notice, agree to properly care for their pass, and commit to immediately reporting lost, damaged, or stolen passes. The form includes a Privacy Act advisement noting that SSN collection is required for record accuracy pursuant to Executive Order 9397 and that all personally identifiable information is protected as required. The issuing official section documents approval or denial decisions, including vetting results, pass number, expiration date, escort requirements, and background check results from NCIC, FBI, and state identification databases. Access denial decisions include category letters and specific charges justifying the denial.
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Text version
REQUEST FOR FORT DEVENS ACCESS CONTROL VISITORS PASS
SECTION BELOW IS FOR USE BY THE INSTALLATION ACCESS CONTROL OFFICE ONLY
PRIVACY ACT ADVISEMENT: The information requested is for the purpose of granting access to the Fort Devens Installation. The
SSN, required for record accuracy, is requested pursuant to EO 9397. All information that contains PII is protected as required.
1. APPLICANT INFORMATION:
Last Name: ______________________First Name: ________________________ Middle Name: _____________________
SSN: _______________________________ Driver’s License #:_________________________________ DL State:_____
Are you a Registered Sex Offender? Yes No Any felony convictions? Yes No Are you a U.S. Citizen? Yes No
Place of Birth (City/State or Country):_______________ Date of Birth (MM/DD/YY): ____________Gender: M___ F
2. REASON FOR VISIT: ______ Non-DoD Contractor/Vendor _____ Foreign National _____ Training / Appointment
______ Family Care Provider _____ Drill / Muster _____ Other ________________________
Have you received a Visitor Pass from Fort Devens within the past year? Yes ____ No____
How many days are you requesting? (01-30 days): _______________________
3. BUILDING NUMBER VISITING: _________________ POC NAME:__________________POC PHONE #:_______________
POCKDKDKD4. APPLICANT CERTIFICATION:
1. I understand that I must give Fort Devens Police consent to an initial and periodic background screenings prior to and after the issuance of an installation access pass. Failure to do so will result in the termination of the application process.
I further understand that these background screenings will determine my eligibility for access and continued access during the term of my requested visit.
2. I understand that my access may be revoked at anytime without reason or notice.
3. I understand that I must properly care for my pass to prevent damage, or unnecessary wear, loss or theft.
4. I understand that I must immediately report any lost, damage or stolen pass to the Fort Devens Police.
5. All the information provided above is true and accurate and I have read all my responsibilities as an applicant for access to Fort Devens and its surrounding facilities.
(Applicant’s Printed Name) (Signature) (Date)
5. ISSUING OFFICIAL: APPROVED / ACCESS DENIED
Vetting results: Renewal ____ NCIC Hit(s) ____ NIR ____
Pass #:_______________________________ Expiration Date: _______________________ Escort Required: Yes____ No____
Category Letter for Access Denial:_________ Access Denial Charge(s):____________________________________________
FBI:______________________
SID:______________________
SID: ______________________
(Issuing Official’s Printed Name) (Signature) (Date)
NCIC Hit(s) Charges:_________________________________________
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Typewritten Text 637, 695
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Typewritten Text Daniel Kobzar
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Typewritten Text
(978) 878-1843
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Typewritten Text x
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Typewritten Text 1 on June 3, 2026
File details come from the government source that posted it. Updated .