Attachment I - Facility Access Request Form

DRUG ENFORCEMENT ADMINISTRATION

Authorization to Conduct Agency-Specific Record Checks
*Privacy Act Protected Information*
I hereby authorize an investigator, special agent, or other duly accredited representative of the Drug EnforcementAdministration to query my Name (including Other Names Used), Social Security Number, Date of Birth, Driver's License, and State it was issued, in its Narcotics and Dangerous Drugs Information System (NADDIS), the National Crime Information Center (NCIC), and the National Law Enforcement Telecommunications System (NLETS) indices for the purpose of unique agency-specific requirements.

Part A. (Access Requestor)
Date of Visit

Request Date
Time of Visit

Company

Facility Access Renewal

Phone Number
Name of Visitor
(Full Legal Name)
DOB
Driver License #

State

Citizenship
SSN
Race

Sex

Purpose of Visit

Signature

Date

Part B. (Facility Employee)
The following personnel will be escorting the visitor:

For questions, please
contact

at extension

This information is required and is to be presented to the Aviation Division Security Officer or Alternate at least 24 hours in advance of the visit for processing through DEA Security. This access is good for 6 months from the approval date.

Requesting Employee

Date

DEA Security Officer

Date

Approved

Denied

PRIVACY ACT STATEMENT

GENERAL: Pursuant to Public Law 93-479 (Privacy Act of 1974), the information is provided for employment purposes. Collection of the social security number is authorized by Executive Order 9397 to help identify individuals because other people may have the same name. AUTHORITY: E.O. 9397; E.O. 10450; E.O. 12356; 5 U.S.C. 1303-1305; 42 U.S.C. 2165 and 2455; 22 U.S.C. 2585 and 2519; and 5 U.S.C. 3301. EFFECT: Failure to provide the necessary information could preclude your suitability for a security clearance or access to sensitive information.