Attachment_2_-_Contractor_Data_Form.pdf

U.S. SECURITIES AND EXCHANGE COMMISSION

100 F Street, N.E., Washington, DC 20549

REQUEST FOR PERSEC DETERMINATION (Contractors)

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

M F

15. Home Street Address 11. E-Mail Address (work) 12. E-Mail Address (personal)

13. Daytime Phone Number 14. Cell Phone Number

16. City 17. State 18. Zip Code 19. Position (Job) Title

20. US Citizen?

YYeses NoNoNo

21. Naturalized Citizen?

Yes No

Non-US Born Citizens Only: Complete 22-24 as applicable

22. Naturalization Certificate Number 23. Alien Registration Number 24. Country of Citizenship

25. Prior Investigation?

Yes No

Prior Federal Investigation Only: Complete 26-28

26. Agency 27. Level of Investigation 28. Date of Completion

Comments (A separate sheet of paper can be included for comments if additional space is needed)

Section B: To Be Completed By SEC Contract Officer Representative (COR)

1. Term of Service

Long Term Temporary less than 6 months

2. Division Supporting

3. Physical Office Location (select one)

ARO BRO CHRO DRO

FWRO LARO MIRO NYRO

PLRO SLRO SFRO HQ/OPC

4. Company Name (Prime)

Name:

5. Company Name (Sub-Contractor, if applicable)

Name:

6. Contract Program Manager

Name:

Phone:

7. Other Contract Point of Contact (if applicable)

Name:

Phone:

8. Contract Number

9. Contract End Date

10. SEC COR

Name:

Phone:

11. Other SEC Point of Contact (if applicable)

Name:

Phone:

Section C: Notes

All documentation must be submitted by the COR to the Personnel Security mailbox at personnelsecurity@sec.gov.

v1. 06/2012

Contractors