## ![](media/image1.png){width="1.2in" height="1.2in"}

<table>
<colgroup>
<col style="width: 17%" />
<col style="width: 1%" />
<col style="width: 14%" />
<col style="width: 13%" />
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Full Name:</td>
<td colspan="4"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="5">Last</td>
<td colspan="4">First</td>
<td colspan="2">M.I.</td>
</tr>
<tr class="odd">
<td colspan="11">Name for workshop badge: <strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="11">Rank, Title, or Position: <strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2"><p><strong>MUST hold SECRET or higher
clearance</strong></p>
<p><strong>Type of clearance:</strong></p>
<p><strong>DOE Q</strong> <strong>L</strong> </p>
<p>Other </p></td>
<td colspan="9"><p>Non-DOE clearances must be faxed by your Facility
Security Officer (FSO) to Sandia Badge Office <u>and</u> to the Workshop
Clearance Coordinator (WCC).</p>
<blockquote>
<p>1<sup>st</sup> fax: Sandia Badge Office, Incoming Classified Visits,
Fax: (505) 284-8812, Phone: (505) 845-8140</p>
<p>2<sup>nd</sup> fax: Jeanette Laslo, WCC, Fax: (505) 845-3651, Phone:
(505)284-5668, email: jlaslo@sandia.gov</p>
</blockquote>
<p><strong>CLEARANCE SUBMITTAL DUE DATE: <u>9/8/08</u></strong></p>
<p><strong>(see page 2 for detailed clearance
instructions)</strong></p></td>
</tr>
<tr class="even">
<td colspan="11">Please provide the following information (*required for
clearance processing):</td>
</tr>
<tr class="odd">
<td colspan="11">*Social Security Number :      </td>
</tr>
<tr class="even">
<td colspan="4">*Birth Date:      </td>
<td colspan="7">*Place of Birth:      </td>
</tr>
<tr class="odd">
<td colspan="6">Business/Organization: <strong>     </strong></td>
<td colspan="5">Telephone: <strong>(     )         </strong></td>
</tr>
<tr class="even">
<td colspan="3"><p>Mailing/street address:</p>
<p>     </p></td>
<td colspan="4"><p>City/State:</p>
<p>     </p></td>
<td colspan="4"><p>Zip Code:</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="3">Mobile Phone : <strong>(    )         </strong></td>
<td colspan="4">Fax: <strong>(    )         </strong></td>
<td colspan="4">email:<strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="11"><strong>Administrative Contact:       Telephone: (    
)          email:      </strong></td>
</tr>
<tr class="odd">
<td colspan="11"><h3 id="section-1"></h3></td>
</tr>
<tr class="even">
<td colspan="11"><h3 id="section-2"></h3></td>
</tr>
<tr class="odd">
<td colspan="2">Workshop Fee</td>
<td colspan="6">Day 1, 9/23/08: Continental Breakfast, Lunch and
refreshments</td>
<td colspan="2"></td>
<td>$30.00</td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="2">Workshop Fee</td>
<td colspan="6">Day 2, 9/24/08: Continental Breakfast, Lunch and
refreshments</td>
<td colspan="2"></td>
<td>$30.00</td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="2">Workshop Fee</td>
<td colspan="6">Day 3, 9/25/08: Continental Breakfast, Lunch and
refreshments</td>
<td colspan="2"></td>
<td>$30.00</td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="2">Social Mixer</td>
<td colspan="6">9/22/08, 6pm, @ MCM Elegante Hotel: Opportunity to
network and receive workshop materials prior to meeting; mixer includes
heavy hor’deurves and no-host bar</td>
<td colspan="2">$16.50 / person # attendees <strong>  </strong></td>
<td>$      </td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="2">Workshop Dinner</td>
<td colspan="6"><p>9/23/08, 7pm @ MCM Elegante Hotel; no-host bar; and
indicate:</p>
<p>Petite Filet w/béarnaise and Tiger Shrimp # <strong>  </strong></p>
<p>Salmon w/orange brandy sauce and Tiger Shrimp #
<strong>  </strong></p></td>
<td colspan="2"><p>$40.00 / person</p>
<p># attendees <strong>  </strong></p></td>
<td>$      </td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="6">TOTAL paid on Webpay via Website:</td>
<td colspan="3">$     </td>
</tr>
<tr class="odd">
<td colspan="11"><em>Please indicate any special dietary requests:</em>
     </td>
</tr>
<tr class="even">
<td colspan="11"><h3 id="section-3"></h3></td>
</tr>
</tbody>
</table>

> **INSTRUCTIONS FOR SENDING CLEARANCES**

**CLEARANCE SUBMITTAL DUE DATE: [9/8/08]{.underline}**

> **[Visitors with DoD/non-DOE Clearances]{.underline}**:
>
> Ensure that the visit request includes the following 10 items:

1.  Name

2.  Social Security Number

3.  Citizenship

4.  Date of Birth

5.  Type of clearance and Date of clearance

6.  Dates of visit: ***9/22/08 - 9/26/08***

7.  Purpose of the visit: ***To attend DoD Innovative Science &
    Technology Electromagnetic (EM) Railgun Workshop***

8.  Person to be visited: ***Ronald J. Kaye, Ph: (505) 845-7658, email:
    rjkaye@sandia.gov***

9.  Place to be visited: ***Sandia National Laboratories, Albuquerque,
    NM***

10. Security officer signature and Security title (the word security
    MUST be in the title)

> Have visitor's facility security officer (FSO) fax clearances directly
> to Sandia's Badge Office Incoming Visits, **Fax: (505) 284-8812**,
> confirmation phone: (505) 845-8140.
>
> Fax copy of visit request to Workshop Clearance Coordinator (WCC):
> Jeanette Laslo, **Fax: (505) 845-3651**, Phone: (505) 284-5668, email:
> jlaslo@sandia.gov .
>
> [NOTE: Sandia Labs does not use JPAS]{.underline}
>
> **[Visitors with a DOE Clearance]{.underline}**:
>
> DOE visitors with Q and L clearances must register for Workshop and be
> U.S. citizens. They do not need to submit a clearance form to the
> Sandia Badge Office. These visitors must register their DOE-issued
> badge at Sandia\'s Badge Office prior to Workshop Registration on
> September 23, 2008.