FNS-814 FNS Visitor Form

OMB APPROVED NO. 0584-0524
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF AGRICULTURE - FOOD, NUTRITION, AND CONSUMER SERVICES

FNS VISITOR BADGE REQUEST FORM

Public reporting burden for this collection of information is estimated to average 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. An agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA
22302 ATTN: PRA (0584-0524). Do not return the completed form to this address.

In accordance with FNS HSPD-12 policy, visitors must be escorted by a permanent FNS employee at all times while on FNS property,
except in areas that are open to the general public. While in an FNS facility, visitor(s) must have their visitor badge displayed at all
times. After this form has been completed, please submit to the Security Office.

Visitor Information
Last Name, First, Middle:

Company/Agency:

Phone:
Email:
Purpose of Visit:

Duration of Visit:

From:

To:

Date/Time

Date/Time

ID Type:

State of Issuance/Country:

Expiration Date:

FNS Sponsor Information
Last Name, First:
Phone:

Program Area:
Room Number of Event:

Sponsor Signature:

Security Completion
Processed by:

Badge Number Issued:

Date:

Security Verification:
Security Officer Approval:

Privacy Act Statement
USDA is authorized to obtain certain information under Section 515 of the Treasury and General Government Appropriations Act for Fiscal
Year 2001 (Public Law No. 106-554, codified at 44 U.S.C. 3516, note). Information is needed by USDA to process the request for correction
and allow USDA to reply accordingly. This information is needed by USDA to respond to the requester and initiate follow-up contact with the
requester if required. Requesters should not send USDA their Social Security Number. Requesters are advised that they do not have to
furnish the information but failure to do so may prevent their request from being processed. The information requesters furnish is almost
never used for any purpose other than to process and respond to their request. However, USDA may disclose information to a
congressional office in response to an inquiry made on behalf of the requester, to the Department of Justice, a court, other tribunal when the
information is relevant and necessary to litigation, or to a contractor or another Federal agency to help accomplish a function
related to this process.
FORM FNS-814 (09-19) Previous Editions Obsolete

SBU

Electronic Form Designed in AEM 6.4 Version