|
Name of Box
|
Who Enters
|
Comments
|
| To |
Group |
Enter the name of the facility to be visited |
| From |
Badge Office |
|
| Date |
Group |
Enter date form is prepared and submitted |
| Prepared by |
Group |
Enter name of Group's Point of Contact |
| Symbol |
Group |
Optional; may be used to designate a memorandum
number, Group abbreviation |
| Telephone No. |
Group |
Group Point of Contact's telephone number |
| Last Name, First, Middle Initial and
Social Security Number |
Group |
Name and SSN of each traveler for the visit.
Use continuation sheet for additional names.
NOTE: If visit is to a non-U.S. facility, the following must
also be included in this box: Place of Birth (City, State, Country),
Home Address, Job Title. If the visit is to a United Kingdom facility,
it is absolutely critical to include traveler(s)' Passport Number
and Expiration Date, plus the VISAM number. |
| Check (Citizenship) |
Group |
|
| Date of Birth |
Group |
|
| Organization |
Group |
Enter "LANL" plus the Group designation |
| Type Clearance |
Badge Office |
|
| Clearance No. |
Badge Office |
|
| Date of Clearance |
Badge Office |
|
| Name of Facility(ies) to be Visited |
Group |
List facility to be visited under this request.
Only list one facility on a single request. |
| For Inclusive Dates |
Group |
Maximum of one year. NOTE:
If the end date is the same as the start date, but one year later,
this is considered one year + one day; make sure the end date is one
day less than the start date but one year later. |
| DOE Security
Official Verifying DOE Clearance |
Badge Office |
Badge Office Security
Officer with approval authority signs if clearance is in order.. |
| For the Purpose of |
Group |
Enter the purpose of the visit to the extent
known |
| To Confer with the Following Person(s) |
Group |
List the host(s) at the facility being visited;
it is extremely helpful to include fax and telephone number
of each host, if unforeseen problems need to be quickly resolved. |
| Specific Information to Which Access
is Requested |
Group |
The classification level and category of
the information to which the traveler needs access including, if appropriate,
nuclear weapon information categories
(Sigma)
or CNDWI |
| Access Requested to |
Group |
Check the appropriate boxes. If "NO" is checked
for both choices, the request for access to classified information
will be denied. |
| Prior arrangements have/have not been
made as follows |
Group |
Describe any advance arrangements that have
been made. |
| Certification for Personnel Having DOD Clearance |
Not Applicable |
Leave blank. NOTE: If a LANL
traveler has a DoD clearance and intends to have that clearance extended
to the DoD facility to be visited, arrangements need to be made directly
with the visiting facility's Security Office. Do NOT
submit the form to the Badge Office. |
| Certification for Personnel Having
a DOE Clearance |
Group |
The Group Leader or Deputy Group Leader signs
and fills in title. The traveler may not sign his/her own request
- a higher level of management must sign. NOTE: If the
visit is to be to the LLNL Weapons Vault or the SNL/NM Weapons Vault,
the Laboratory Director or designee must sign here and
is the only person who can sign. |
| Part "B" |
Not Applicable |
Do NOT sign in this section.
Leave blank. |