Attachment_7_-_Request_for_PERSEC_Determination.pdf
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- Attached to
- Leading Author Services
- Solicitation number
- 62000-17-9905
- Issued by
-
Securities and Exchange Commission
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PERSEC
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Text version
v1. 06/2012
Section A: To Be Completed By the Applicant
1. Name (Last/Family) 2. First (Given) 3. Middle (or NMN) 4. Other Names Used 5. Suffix
6. Social Security Number 7. Date of Birth MM/DD/YYYY 8. Place of Birth (City and State) 9. Country 10. Gender
13. Daytime Phone Number 14. Cell Phone Number
15. Home Street Address 11. E-Mail Address (work) 12. E-Mail Address (personal)
16. City 17. State 18. Zip Code 19. Position (Job) Title
20. US Citizen?
24. Country of Citizenship
Non-US Born Citizens Only: Complete 22-24 as applicable
22. Naturalization Certificate Number 23. Alien Registration Number
Section B: To Be Completed By SEC Contract Officer Representative (COR)
1. Term of Service 4. Company Name (Prime) 8. Contract Number
U.S. SECURITIES AND EXCHANGE COMMISSION
100 F Street, N.E., Washington, DC 20549
REQUEST FOR PERSEC DETERMINATION (Contractors)
Comments (A separate sheet of paper can be included for comments if additional space is needed)
25. Prior Investigation? Prior Federal Investigation Only: Complete 26-28
26. Agency 27. Level of Investigation 28. Date of Completion
21. Naturalized Citizen?
5. Company Name (Sub-Contractor, if applicable)2. Division Supporting
Name:
All documentation must be submitted by the COR to the Personnel Security mailbox at personnelsecurity@sec.gov.
9. Contract End Date
Name:
6. Contract Program Manager
Name:
10. SEC COR
Name:
3. Physical Office Location (select one)
Phone:Phone:
7. Other Contract Point of Contact (if applicable) 11. Other SEC Point of Contact (if applicable)
Name:Name:
Phone:
Section C: Notes
Phone:
Long Term Temporary less than 6 months
Yes
Yes No
No
M F
ARO BRO CHRO DRO
FWRO LARO MIRO NYRO
PLRO SLRO SFRO HQ/OPC
Yes No No No Yes
Contractors
| 1 Name LastFamily: |
| 2 First Given: |
| 3 Middle or NMN: |
| 4 Other Names Used: |
| 5 Suffix: |
| 6 Social Security Number: |
| 7 Date of Birth MMDDYYYY: |
| 8 Place of Birth City and State: |
| 9 Country: |
| 15 Home Street Address: |
| 11 EMail Address work: |
| 12 EMail Address personal: |
| 13 Daytime Phone Number: |
| 14 Cell Phone Number: |
| 16 City: |
| 17 State: |
| 18 Zip Code: |
| 19 Position Job Title: |
| 23 Alien Registration Number: |
| 24 Country of Citizenship: |
| 27 Level of Investigation: |
| 28 Date of Completion: |
| Comments A separate sheet of paper can be included for comments if additional space is needed: |
| 4 Company Name Prime Name: |
| 8 Contract Number: |
| 2 Division Supporting: |
| 5 Company Name SubContractor if applicable Name: |
| 9 Contract End Date: |
| Section C NotesRow1: |
| Agency: |
| Naturalization Certificate Number: |
| 6 Contract Program Manager Name: |
| 6 Contract Program Manager Phone: |
| 7: |
| Other Contract Point of Contact Name: |
| Other Contract Point of Contact Phone: |
| 10 SEC COR Name: |
| 10 SEC COR Phone: |
| 11: |
| Other SEC Point of Contact Name: |
| Other SEC Point of Contact Phone: |
| Gender Male: Off |
| Gender Female: Off |
| US Citizen YES: Off |
| US Citizen NO: Off |
| Naturalized Citizen YES: Off |
| Naturalized Citizen NO: Off |
| Prior Investigation YES: Off |
| Prior Investigation NO: Off |
| Long Term (greater than 6 months): Off |
| Temporary (less than 6 months): Off |
| ARO: Off |
| BRO: Off |
| CHRO: Off |
| DRO: Off |
| FWRO: Off |
| LARO: Off |
| MIRO: Off |
| NYRO: Off |
| PLRO: Off |
| SLRO: Off |
| SFRO: Off |
| HQ/OPC: Off |
File details come from the government source that posted it. Updated .