VIS User Requests

OMB Control No. 1625-0070
Exp: 12/31/2015

United States Coast Guard
Vessel Identification System User Request Form
Fax completed form to 202-372-1922; Attn: Ervin Boyd.

Requesting VIS user
First & Last Name:
Agency:

U. S. Citizen:

Contract Employee:
If Yes has background
check been completed?

Request from PSAP:
E-Mail Address:
Business Phone:
Supervisor Name:
Supervisor
E-Mail Address:
Supervisor Phone #:
Supervisor Fax #:

YES

NO

YES

NO

YES

NO

YES

NO

WARNING:
Unauthorized access is prohibited by Title 18 USC Section 1030. Unauthorized access
may also be a violation of other Federal Law or government policy, and may result in
criminal and/or administrative penalties. Users shall not access other users' or system
files without proper authority. Absence of access controls IS NOT authorization for
access! USCG information systems and related equipment are intended for
communication, transmission, processing, and storage of U.S. Government information.
These systems and equipment are subject to monitoring to ensure proper functioning,
protect against improper or unauthorized use or access, and verify the presence of
performance of applicable security features or procedures, and other like purposes.
Such security monitoring may result in the acquisition, recording and analysis of all
data being communicated, transmitted, processed or stored in this system by a user. If
security monitoring reveals evidence of possible criminal activity, such evidence may
be provided to law enforcement personnel. Use of this system constitutes consent to
such security monitoring.

Authorization to Automated Information System:
System - Vessel Identification System (VIS) Version 2.0.0
This system is made available for authorized VIS users
SCOPE OF AUTHORIZATION:
Subject to limitations which follow, upon receipt of Username and Password the
user is authorized access to the computer system(s) identified above. This
authorization contains no implied authorization to access any computer systems
of the United States Government not specifically identified herein and will be
revoked on separation, retirement, reassignment of duties, change of
organization, or when determined by the Information System Security Officer to
be in the best interest of the Government.
ACKNOWLEDGEMENT:
By signing this form I agree that I have read the above warnings and
authorization. I understand that I am authorized to access the computer
system(s) identified above and that accessing them for purposes beyond the
scope of Authorization is a violation of Federal law (18 U.S.C. 1030 et al). My
password meets the DHS Information System Security requirements, and I may
be held responsible for my inappropriate protection or sharing of my password.
User names & passwords will not be issued until the user request form has
been received with the User & Authorizing Official signatures.
User Signature & Date:
Supervisor Signature & Date:
USCG ISSO Signature & Date: