Please make a hard copy of this form, fill it out, have
it signed by the person authorizing this visit from your command/company and
fax it to NRL Security at:
831-656-4314. For questions
regarding this form and visitor procedures please call our security department
at: 831-656-4613. All fields must be filled in or request
will be denied.
From: Your organization or command information:
Command/Company
Name: ______________________________________________________
Address:
_____________________________________________________________________
Phone: ______________________________ FAX: ___________________________________
Foreign Government Agency
Representative?: No Yes
Date of Request: ______/______/______
Duration of Visit: Arrival date: ______/______/______ Departure date:
______/______/______
Point of Contact at NRL:
____________________________________________________________
Purpose of Visit/remarks:
_______________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Your Full Name: ______________________________________________________________________
Your Rank/Title/Position: _______________________________________________________________
Email: _________________________________________ Phone: _____________________________
Social Security Number: ______-______-______
Date of Birth: ______/______/_____ Place of Birth: _______________________________________
Citizenship: US Resident Alien Other (specify): _________________________________
INS Registration Number: _____________________________
Security Clearance: None Secret Top Secret
Agency granting clearance: _____________________
Date of investigation: ______/______/______ Type of investigation: _________________________
This section is to be completed by the person in your organization that authorizes travel and security information. This form is not to be signed by the person requesting to visit!
Authorizing Name: ____________________________________________________________________
Your Rank/Title/Position: _______________________________________________________________
Authorizing email: _______________________________ Phone: ______________________________
Authorizing signature (REQUIRED): ____________________________________________________