Attachment #8 - USSS Security Access Forms.pdf

14. LENGTH OF TIME YOU

WORKED FOR THIS

EMPLOYER

Years

Months

20. ARE THERE ANY PENDING CHARGES AGAINST YOU

BEFORE A CIVIL OR CRIMINAL COURT?

5. USSS CONTRACT NUMBER (required for all contractors)

4. COMPANY/AGENCY AND POSITION TO BE HELD OR OTHER DUTIES PERFORMED

16. DO YOU HOLD U.S. CITIZENSHIP STATUS?

DOES THE APPLICANT HAVE A DD-254 ON FILE?

7. TYPE OF APPLICANT

17. IF YOU ARE A U.S. CITIZEN OTHER THAN BY BIRTH, PROVIDE THE FOLLOWING:

8. SEX

DEPARTMENT OF HOMELAND SECURITY

United States Secret Service

U.S. SECRET SERVICE FACILITY ACCESS REQUEST

1. FULL NAME (last, first, middle) 2. MAIDEN NAME (if applicable)

4. SOCIAL SECURITY NUMBER3. OTHER ALIAS (last, first, middle)

7. DRIVERS LICENSE NO. AND STATE6. PLACE OF BIRTH (city, state, country)5. DATE OF BIRTH (month/day/year)

WEIGHT HAIR COLOR 9. RACEEYE COLORHEIGHT American Indian or Alaskan Native Hispanic or Latino Female Asian Native Hawaiian or other

Pacific Islander Male Black or African American White

12. TELEPHONE (area code, number)10. PRESENT ADDRESS (street address, city, state, zip code) 11. DO YOU HAVE AN

UNEXPIRED DHS PIV

CARD?

Work:

YES

Residence:

NO

Cellular:

15. NAME OF SUPERVISOR AND TELEPHONE NUMBER (with area code)13. NAME AND ADDRESS OF EMPLOYER (company/agency)

Naturalization Certificate No.:

Date of Issuance:

Page 1 of 2SSF 3237 (Rev. 07/2015)

SECTION A - TO BE COMPLETED BY THE U.S. SECRET SERVICE RESPONSIBLE OFFICE

1. NAME OF USSS RESPONSIBLE

OFFICE

3. CONTACT'S USSS E-MAIL ADDRESS

SECTION B - TO BE COMPLETED BY APPLICANT

PLEASE READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM

6. IS THIS A CLASSIFIED PROGRAM/CONTRACT?

YES NO

NO

YES NO

Form Approved: O.M.B. Control No. 1620-0002, Expiration Date: 11/30/2019

CONTRACTOR DETAILEE/JDA GOVERNMENT EMPLOYEE OUTSIDE OF THE SECRET

SERVICE (frequent visitor for official business)

OTHER:

8. SPECIFY THE TYPE OF ACCESS THAT THIS APPLICANT REQUIRES (you must select one category):

CATEGORY 1 (NON ROUTINE FACILITY ACCESS/ NO ACCESS TO INFORMATION TECHNOLOGY (IT) /NO ACCESS TO PERSONALLY

IDENTIFIABLE INFORMATION (PII)).

CATEGORY 1 ACCESS GRANTS THE APPLICANT TWO YEAR ACCESS.

IF LESS THAN TWO YEARS ACCESS, PLEASE INDICATE ACCESS EXPIRATION DATE:

YES

SECTION B CONTINUES ON PAGE 2

Company name:

Street address:

City, State, ZIP:

CATEGORY 2 (ROUTINE FACILITY ACCESS AND NO IT ACCESS OR ACCESS TO PII).

CATEGORY 2 ACCESS GRANTS THE APPLICANT FIVE YEAR ACCESS.

IF LESS THAN FIVE YEARS ACCESS, PLEASE INDICATE ACCESS EXPIRATION DATE:

CATEGORY 3 (IT ACCESS AND/OR ACCESS TO PII REGARDLESS OF FACILITY ACCESS).

CATEGORY 3 ACCESS GRANTS THE APPLICANT FIVE YEAR ACCESS.

IF LESS THAN FIVE YEARS ACCESS, PLEASE INDICATE ACCESS EXPIRATION DATE:

19. HAVE YOU EVER BEEN CONVICTED OF ANY

CRIMINAL OFFENSE?

18. HAVE YOU EVER BEEN ARRESTED, CHARGED,

OR INDICTED FOR A CRIME?

YES NO YES NO YES NO

2. NAME OF USSS POINT OF CONTACT (Last, First, Middle)

NOTE: I understand than any false statement on any part of my application may be grounds for denying me access into Secret Service controlled facilities, and/or grounds for prosecution under Title 18 U.S.C. 1001.

The estimated average burden associated with this collection of information is Comments and or suggestions concerning the accuracy of this burden estimate and for reducing this burden should be directed to the Secret Service at this address: Communications Center (MNO), 245 Murray Lane, SW, Building T5, Washington, DC 20223; and to the Office of Management and Budget, Paperwork Reduction Project (1620-0002), Washington, DC 20503.

In accordance with 5 CFR 1320.5(b), a Government agency may not conduct or sponsor, and a person is not required to complete, a collection of information unless the collection of information displays a valid OMB control number.

PUBLIC BURDEN INFORMATION

minutes per respondent or recordkeeper.15

Page 2 of 2SSF 3237 (Rev. 07/2015)

Form Approved: O.M.B. Control No. 1620-0002, Expiration Date: 11/30/2019

SECTION B - CONTINUED FROM PAGE 1

This authorization is given in connection with the investigative procedures being conducted relative to my contractual services with the U.S. Secret Service, and/or access to secure areas occupied by the U.S. Secret Service.

(signature of applicant)

22. DATE21. SIGNATURE OF APPLICANT

RELEASE STATEMENT - TO BE COMPLETED BY APPLICANT

This release when presented by a duly authorized representative of the U. S. Secret Service will constitute my consent and authority to obtain any information relating to my activities from criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail businesses, or other sources of information. The information may include my criminal history record information and financial and credit information.

Specifically, I hereby authorize the release of Federal/State/Local Police & Criminal Records or data to the U.S. Secret Service by applying my signature on the designated line below.

My signature further authorizes the U.S. Secret Service (or other component of the Department of Homeland Security) to obtain one or more consumer credit reports about me pursuant to the Fair Credit Reporting Act from any consumer credit reporting agency. Copies of this authorization that show my signature are as valid as the original signed by me.

INSTRUCTIONS:

1. Please TYPE or PRINT clearly with a dark ball point pen.

2. To apply for access into U.S. Secret Service controlled facilities, the applicant must complete this form in its entirety. (Failure to properly complete this form can result in delays and/or non admittance into U.S.

Secret Service controlled facilities.)

3. A representative from the U.S. Secret Service Responsible Office must submit this completed form to the U.S.

Secret Service Security Management Division at least five business days prior to the anticipated access date for Category 1 applicants. For Category 2 and Category 3 applicants, the USSS responsible office must submit this completed form to the Security Management Division at least 10 business days prior to the anticipated access date.

4. A DD-254 form is required for all contractor positions requiring a security clearance. By selecting "YES" for Section A, Item 9, you are verifying that a DD-254 is on file for the contract identified in Section A, Item 5 (DD-254 requirements are not applicable for detailees).

5. Note that the applicant must sign this form TWICE: once under the release statement at the top of this page, and again at item 21.

6. If there are any questions regarding this form, please contact the Security Management Division at 202-406-6658.

Privacy Act Statement: All information requested on the U.S. Secret Service Facility Access Request is collected under authority derived from 18 U.S.C. 3056 and Executive Order 9397. The routine uses of information requested include referral to other Federal, State and Local agencies for determining suitability for access to secure areas, and/or sensitive, unclassified material of the U.S. Secret Service. Submission of the information is voluntary, however, failure to provide information requested may prohibit processing and cause denial of access to secure areas or sensitive material protected by the U.S. Secret Service. Disclosure of your Social Security Account Number is voluntary. The information is used to identify and separate individuals with similar or identical names or initials.

Refusal to disclose your Social Security Number will be no cause for denial of any right, benefit or privilege provided by law.

DEPARTMENT OF HOMELAND SECURITY

United States Secret Service

CONDITIONAL ACCESS TO SENSITIVE BUT UNCLASSIFIED INFORMATION

NON-DISCLOSURE AGREEMENT

I, , hereby consent to the terms in this Agreement in consideration of my being granted conditional access to certain United States Government documents or material containing sensitive but unclassified information.

I understand and agree to the following terms and conditions:

1. By being granted conditional access to sensitive but unclassified information, the United States Government has placed special confidence and trust in me and I am obligated to protect this information from unauthorized disclosure, in accordance with the terms of this Agreement.

2. As used in this Agreement, sensitive but unclassified information is any information which the loss of, misuse of, or unauthorized access to or modification of could adversely affect the national interest or the conduct of Federal programs, or the privacy to which individuals are entitled under Title 5, U.S.C., Section 552a, but which has not been specifically authorized under criteria established by an Executive Order or an Act of Congress to be kept secret in the interest of national defense or foreign policy.

3. I am being granted conditional access contingent upon my execution of this Agreement for the sole purpose of (identify) This approval will permit me conditional access to certain information, e.g., (check type(s) of information that apply) documents, memoranda, reports, testimony, deliberations, maps, drawings, schematics, plans, assessments, etc.) and/or to attend meetings where such information is discussed or otherwise made available to me. This Agreement will not allow me access to materials which the United States Secret Service has predetermined, in its sole discretion, are inappropriate for disclosure pursuant to this Agreement. This may include sensitive but unclassified information provided to the United States Secret Service by other agencies of the United States Government.

4. I will never divulge any sensitive but unclassified information which is provided to me pursuant to this Agreement to anyone, unless I have been advised in writing by the United States Secret Service that the individual is authorized to receive it. Should I desire to make use of any sensitive but unclassified information, I will do so in accordance with paragraph 6 of this Agreement. I will submit to the United States Secret Service for security review, prior to any submission for publication, any book, article, column or other written work for general publication that is based upon any knowledge I obtained during the course of my work on (identify) in order for the United States Secret Service to ensure that no sensitive but unclassified information is disclosed.

5. I hereby assign to the United States Government all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of sensitive but unclassified information not consistent with the terms of this Agreement.

6. I hereby agree that when reviewing any official documents containing sensitive but unclassified information, such review will be conducted at a secure facility or under circumstances which will maintain the security protection of such material. I will not be permitted to and will not make any copies of documents or parts of documents to which conditional access is granted to me. Any notes taken during the course of such access will remain at the United States Secret Service, to be placed in secure storage unless it is determined by the United States Secret Service that the notes contain no sensitive but unclassified information. If I wish to have the notes released to me, United States Secret Service officials will review the notes for the purposes of deleting any sensitive but unclassified information to create a redacted copy of the notes. If I do not wish a review of any notes that I make, those notes will remain sealed in secure storage at the United States Secret Service.

(Over)

SSF 4024 (Rev. 01/2015) Page 1 of 2

7. If I violate the terms and conditions of this Agreement, I understand that the unauthorized disclosure of sensitive but unclassified information could compromise the security to the United States Secret Service.

8. If I violate the terms and conditions of this Agreement, such violation may result in the cancellation of my conditional access to sensitive but unclassified information. This may serve as a basis for denying me conditional access to United States Secret Service information, both classified and sensitive but unclassified information in the future. If I violate the terms and conditions of this Agreement, the United States may institute a civil action for damages or any other appropriate relief. The willful disclosure of information to which I have agreed therein not to divulge may constitute a criminal offense.

9. Until I am provided a written release by the United States Secret Service from this Agreement or any portions of it, all conditions and obligations contained in this Agreement apply both during my period of conditional access, which shall terminate at the conclusion of my (identify) , and at all times thereafter.

10. Each provision of this Agreement is severable. If a court should find any provision of this Agreement to be unenforceable, all other provisions shall remain in full force and effect.

11. I understand that the United States Government may seek any remedy available to it to enforce this Agreement, including, but not limited to, application for a court order prohibiting disclosure of information in breach of this Agreement.

12. By granting me conditional access to information in this context, the United States Government does not waive any statutory or common law evidentiary privileges or protections that it may assert in any administrative or court proceeding to protect any sensitive but unclassified information to which I have been given conditional access under the terms of this Agreement

13. These restrictions are consistent with and do not supersede, conflict with or otherwise alter the employee obligations, rights or liabilities created by Executive Order 12356; Section 7211 of Title 5, United States Code (governing disclosures to Congress); Section 1034 of Title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); Section 2302 (b) (8) of Title 5, United States Code, as amended by the Whistleblower Protection Act (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); the Intelligence Identities Protection Act of 1982 (50 U.S.C.

4212 et seq.) (governing disclosures that could expose confidential Government agents), and the statutes which protect against disclosure that may compromise the national security, including Sections 641, 793, 794, 798, and 952 of Title 18, United States Code, and Section 4(b) of the Subversive Activities Act of 1950 (50 U.S.C. Section 783(b)). The definitions, requirements, obligations, rights, sanctions and liabilities created by said Executive Order and listed statutes are incorporated into this Agreement and are controlling.

14. My execution of this Agreement shall not nullify or effect in any manner any other secrecy or nondisclosure Agreement which I have executed or may execute with the United States Government.

15. I make this Agreement in good faith, without mental reservation or purpose of evasion.

SIGNATURE DATE

This Agreement was accepted by the undersigned on behalf of the United States Secret Service as a prior condition of conditional access to sensitive but unclassified information.

WITNESSED BY - UNITED STATES SECRET SERVICE DATE

This form is not subject to the requirements of P. L. 104-13, "Paperwork Reduction Act of 1995" 44 USC, Chapter 35.

SSF 4024 (Rev. 01/2015) Page 2 of 2