DOE F 5631.20 US Department of Energy Request for Visit or Access Appr

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DOE F 5631.20
(07-90)
(Formerly DP-277)
EFG (07-90)

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U.S. DEPARTMENT OF ENERGY
REQUEST FOR VISIT OR ACCESS APPROVAL
(Not to be used for temporary or permanent personnel assignments.)
Part “A”

OMB Control No.
1910-1800
Burden Disclosure Statement
on last page

Date:
To:

Link to Guidelines

Prepared By:
Symbol:

From:

Telephone No.Commercial:
It is requested that the following person(s) be granted visit/access approval:

FTS:

CHECK
LAST NAME, FIRST, MIDDLE INITIAL
AND SOCIAL SECURITY NUMBER

U.S.
CITIZEN

ALIEN

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DATE OF
BIRTH
(MM/DD/YY)

NAME OF FACILITY(IES) TO BE VISITED:

TYPE
CLEARANCE

ORGANIZATION

FOR INCLUSIVE DATES

CLEARANCE
NO.

DATE OF
CLEARANCE
(MM/DD/YY)

DOE Security Official Verfying DOE Clearance
_________________________________________

FOR THE PURPOSE OF:

______________________________________________________________________________________________________________________________
TO CONFER WITH THE FOLLOWING PERSON(S):

______________________________________________________________________________________________________________________________
SPECIFIC INFORMATION TO WHICH ACCESS IS REQUESTED:

ACCESS REQUESTED TO:

Restricted data:
Other classified info:

† Yes
† Yes

† No
† No

Prior arrangement have/have not been made as follows: NOTE: Always include the fax to send this request to. A telephone number is also helpful.
CERTIFICATION FOR PERSONNEL HAVING DOD CLEARANCE
This certifies that the person(s) named above needs this access in the performance of duty and that permitting the above access will not endanger the
common defense and security.
Authorized access to Critical Nuclear Weapon
Design Information (CNWDI) in Accordance
With DOD Directive 5210.2
† Yes † No

__________________________________________________
Name and Title, Requesting DOD Official

_______________________________________________________

_______________________________________________________

Title, Authorizing DOD Official
(See DOD Directive 5210.2 and 5210.8)

Signature
(See AR 380-150; OPNAV 5510.3F; AFR 205-1)

CERTIFICATION FOR PERSONNEL HAVING DOE CLEARANCE
This certifies that the person(s) named above needs this access in the performance of duty.

_______________________________________________________

_______________________________________________________

Title

Requesting DOE or Other Government Agencies

PART “B”
Approval is granted with limitations indicated below:

_______________________________________________________
Manager of Operations/or Headquarters Division Director

Form DOE5631.20 (LANL 12/01)

SEE LAST PAGE FOR PRIVACY ACT INFORMATION STATEMENT

SAVE

PRINT

CLEAR FORM

THIS PAGE IS VALID ONLY FOR CLASSIFED VISITS TO LANL
LANL continuation sheet to
DOE F 5631.20
(07-90)
(Formerly DP-277)
EFG (07-90)

Continuation Page

LANL
Name of Facility(ies) to be Visited _________________________________________________

For Inclusive Dates ________________________

CHECK
LAST NAME, FIRST, MIDDLE INITIAL
AND SOCIAL SECURITY NUMBER

U.S.
CITIZEN

ALIEN









































DATE OF
BIRTH
(MM/DD/YY)

ORGANIZATION

TYPE
CLEARANCE

CLEARANCE
NO.

DATE OF
CLEARANCE
(MM/DD/YY)

LANL POLICY: THE SECTION BELOW MUST BE COMPLETED THE SAME AS ON THE FIRST SHEET
CERTIFICATION FOR PERSONNEL HAVING DOD CLEARANCE
This certifies that the person(s) named above needs this access in the performance of duty and that permitting the above access will not endanger the
common defense and security.
Authorized access to Critical Nuclear Weapon
Design Information (CNWDI) in Accordance
With DOD Directive 5210.2
† Yes † No

__________________________________________________
Name and Title, Requesting DOD Official

_______________________________________________________

_______________________________________________________

Title, Authorizing DOD Official
(See DOD Directive 5210.2 and 5210.8)

Signature
(See AR 380-150; OPNAV 5510.3F; AFR 205-1)

CERTIFICATION FOR PERSONNEL HAVING DOE CLEARANCE
This certifies that the person(s) named above needs this access in the performance of duty.

_______________________________________________________

_______________________________________________________

Title

Requesting DOE or Other Government Agencies

PART “B”
Approval is granted with limitations indicated below:

SAVE

PRINT

CLEAR FORM

_______________________________________________________
Manager of Operations/or Headquarters Division Director

Form DOE5631.20 (LANL 12/01)

Page ___ of ___

THIS PAGE IS VALID ONLY FOR CLASSIFED VISITS TO LANL

DOE F 5631.20
(07-90)
(Formerly DP-277)
EFG (07-90)

PRIVACY ACT INFORMATION STATEMENT

Collection of the information requested is authorized by Section 145 of the Atomic
Energy Act of 1954, as amended (PL 83-703, 42 USC 2165). Compliance with this
request is voluntary; however, if the information submitted is inadequate or incomplete,
approval for your visit to a classified DOE facility, or your access to classified information may be delayed or withheld. The information you furnish will be used by DOE
and DOE contractors to control access to classified information and areas.
The social security number is not required for these purposes, but you may voluntary
furnish it to assist us in correct identification.

BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 2.5
minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing
this burden, to Office of Information Resources Management Policy, Plans, and Oversight, AD-241-2 - GTN, Paperwork Reduction Project (1910-1800), U.S. Department of
Energy 1000 Independence Avenue, S.W., Washington, DC 20585; and to the Office
of Management and Budget 90MB), Paperwork Reduction Project (1910-1800),
Washington, DC 20503.

Form DOE5631.20 (LANL 12/01)

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