CBP_Form_77_Contractor_Empl_Initial_BI.pdf

CONTRACTOR EMPLOYEE INITIAL BACKGROUND INVESTIGATION

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

CBP Form 77 (07/11)

Instructions: This form will be used to request and obtain the necessary information to begin a contractor employee's background investigation. The contractor employee (or the contractor Program Manager on behalf of the contractor employee) must complete the form. Upon completion of Sections A and B, the contractor employee or the contractor Program Manager must return the form to the COTR. Upon receipt of the form, the Contracting Officer's Technical Representative (COTR) shall complete Section C and submit the form to the Electronic Questionnaires for Investigations Processing (e-QIP) initiator for action.

A. Contractor Employee Full Legal Name:

Social Security Number:

Date of Birth:

Place of Birth (Include City, State or Country):

Email Address:

Phone Number:

Contractor Employee will require Systems Access:

Date to be Assigned to Customs Project:

Work Location:

Work Phone Number(s):

Employee’s Supervisor:

Employee’s Supervisor Phone Number:

B. Contractor Company Company Name:

Contract Number:

Contract Manager:

Contract Manager’s Phone Number:

Employee Contract Obligation Will End:

Contract Manager's Signature X

C. Customs and Border Protection COTR Name:

Organization:

Phone Number:

Location:

D. Customs and Border Protection e-QIP Initiator Date Background Investigation Paperwork Received:

Initiator's Signature X Privacy Act Statement: The U.S. Government conducts background investigations and reinvestigations to establish that applicants or incumbents either employed by the government or working for the government under contract are suitable for the job. The U.S. Government is authorized to ask for this information under Executive Orders 10450 and 10577, sections 3301 and 3302 of title 5, U.S. Code; and parts 5, 731, 732 and 736 Title 5, Code of Federal Regulations. Providing the requested Background Investigation information is voluntary, however if you choose not to provide the required information it may affect your placement or employment prospects. The information you provide is for the purpose of investigating you for a position. The collection, maintenance, and disclosure of background investigative material are governed by the Privacy Act.

COTR's Signature X

New Contractor Employee Transfer Employee

Date:

Date:

CONTRACTOR EMPLOYEE INITIAL BACKGROUND INVESTIGATION

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection CBP Form 77 (07/11) Instructions: This form will be used to request and obtain the necessary information to begin a contractor employee's background investigation. The contractor employee (or the contractor Program Manager on behalf of the contractor employee) must complete the form. Upon completion of Sections A and B, the contractor employee or the contractor Program Manager must return the form to the COTR. Upon receipt of the form, the Contracting Officer's Technical Representative (COTR) shall complete Section C and submit the form to the Electronic Questionnaires for Investigations Processing (e-QIP) initiator for action.

A. Contractor Employee Full Legal Name:

Social Security Number:

Date of Birth:

Place of Birth (Include City, State or Country):

Email Address:

Phone Number:

Contractor Employee will require Systems Access:

Date to be Assigned to Customs Project:

Work Location:

Work Phone Number(s):

Employee’s Supervisor:

Employee’s Supervisor Phone Number:

B. Contractor Company Company Name:

Contract Number:

Contract Manager:

Contract Manager’s Phone Number:

Employee Contract Obligation Will End:

Contract Manager's Signature X C. Customs and Border Protection COTR Name:

Organization:

Phone Number:

Location:

D. Customs and Border Protection e-QIP Initiator Date Background Investigation Paperwork Received:

Initiator's Signature X Privacy Act Statement: The U.S. Government conducts background investigations and reinvestigations to establish that applicants or incumbents either employed by the government or working for the government under contract are suitable for the job. The U.S. Government is authorized to ask for this information under Executive Orders 10450 and 10577, sections 3301 and 3302 of title 5, U.S. Code; and parts 5, 731, 732 and 736 Title 5, Code of Federal Regulations. Providing the requested Background Investigation information is voluntary, however if you choose not to provide the required information it may affect your placement or employment prospects. The information you provide is for the purpose of investigating you for a position. The collection, maintenance, and disclosure of background investigative material are governed by the Privacy Act.

COTR's Signature X New Contractor Employee Transfer Employee Date:

Date:

8.2.1.4029.1.523496.503679