70FA5018R00000014_B405_AMENDMENT_A00001.pdf

FEMA Form 121-3-1-6, 4/13

DEPARTMENT OF HOMELAND SECURITY

FEDERAL EMERGENCY MANAGEMENT AGENCY

CONTRACT FITNESS/SECURITY SCREENING REQUEST

Please refer to the instructions when completing this form. Incomplete forms will be returned. This form must be submitted electronically to FEMA-OCSO-CONTRACTOR-COMPLIANCE-SECTION@FEMA.DHS.GOV by the CO, COR, or Federal POC.

Positions requiring SCI access must be reviewed and submitted by the Office/Directorate SSO

(FEMA-OCSO-SSO@DHS.FEMA.GOV).

Request Type: Please select the type of request

Section I: Requesting Official/Organization

Section II: Individual to be Screened

For UNCLASSIFIED CONTRACT'S, please complete Section III. Section III: Position Designation (Please CHECK ONLY ONE)

For CLASSIFIED CONTRACT'S, please complete Section IV. Section IV: Position Security Clearance Requirement (Please CHECK ONLY ONE)

Privacy Information AUTHORITY: 5USC 5701-5733, Sections 5701-5733 and Executive Order 9397. DISCLOSURE: Disclosure of information is voluntary.

PURPOSE: To identify the applicant precisely when processing the requested action.

(1) Denotes fields required for completing an Exit Request. This form must be submitted electronically to FEMA-OCSO-CONTRACTOR- COMPLIANCE-SECTION@FEMA.DHS.GOV by the CO, COR, or Federal POC.

Instructions: A DD-254 form is required for all contractor positions requiring a security clearance. By selecting “Yes” in the DD254 on File box below, you are verifying that a DD-254 is on file for the contract identified above. For positions not requiring a clearance, please indicate a Position Designation in Section III above.

Applicants Full Name

Applicant Currently on Contract with DHS Components:

Non-IT Position Risk Level:

IT Position Risk Level:

Security Clearance Level: * Approved by SSO:

* 9 For Buildings Access ONLY - No Access to FEMA Systems/Information is Required)

If Yes, Please Indicate DHS Component:

Place of Birth

Contracting Officer (CO):

Prime Contractor: (1)

Name of Contracting Officer Rep (COR)/ Contracting Officer (CO) or Federal Point of Contact (POC): (1)

Date (mm/dd/yr)

Name of Contracting Officer (CO)

Name

Name

Last First Middle

Telephone Number

Telephone Number

Telephone Number

Prime Contract Number:

Applicant Position Title: (1)

Social Security Number (1) Date of Birth City Country (if not US)

Applicants E-Mail Address: Applicants Daytime Phone Number:

Begin Date (1) End Date (1)

Task Order Number FEMA Organization/Division Name: (1)

Gender

State

DD254 on File

New Request New Request (Reciprocity) Position Change

Contract Change Dual Change Name Change Exit Request (1)

Yes No

DHS HQ

USGC

CBP FEMA FLETC TSA

USSSUSICEUSCIS

Background Invest. Type-Date Investigative Agency Clearance Granted (If any) -Level & Date

Low Risk* Moderate Risk (5N) High Risk (6N)

Moderate Risk (5C) High Risk (6C)

Secret Top Secret SCI* Yes No

General

The FEMA Form 121-3-1-6, Contractor Fitness/Security Screening Request Form is used by FEMA federal employees to request that the Office of the Chief Security Officer, Personnel Security Division (PSD) perform the appropriate fitness screening on contractor employees based on the risk level of their position. The risk level is based on an overall assessment of the damage that an untrustworthy individual could cause to the efficiency or the integrity of FEMA operations. When determining risk levels, program officials may compare the individual's duties, responsibilities, and access with those of FEMA federal employees in similar positions.

The position designation is critical to the contractor fitness process in that it determines the investigative requirements associated with the position. For example, the minimum investigative standard for a Moderate Risk Public Trust position is a Minimum Background Investigation (MBI) conducted within the last 5 years. If during the fitness process it is determined that the individual has been investigated by another federal agency, FEMA may use that investigation(s) whenever practical. However, if the investigation is out of date (scope), or not at the required level for the position, FEMA will need to initiate a new or upgraded background investigation and incur the costs associated with the investigation.

On Classified Contracts a few or all positions may require access to national security information (NSI). In this case, the contractor employee must have an active clearance already in place prior to being permitted to perform on a FEMA contract. The clearance must meet or exceed the level designated by the FEMA position and must be visible in the JPAS Database.

FEMA does not sponsor National Security background investigations or grant security clearances to contract employees.

Contractor Employee Clearances - Please note that FEMA recognizes contract employee clearance levels based on the risk or access level designated to the FEMA contract position. For example, a contract employee may be eligible through their company and DISCO for access at the Top Secret level, however, if the FEMA contract position is designated at the Secret level, then the position and associated PIV card or badge is marked at the Secret level, not the Top Secret level. Using the same example, if the FEMA position is designated as a Public Trust position (i.e., unclassified contracts - low thru high risk), then the position and associated PIV card or badge is marked with no security clearance. Basically, the security clearance level is associated with the position working in, and not the individual.

Section - Request Type

Please enter the date of the request, and select at least one of the following request types:

New Request - Select “New Request” when the contractor employee is new to the Office or

Directorate.

New Request (Reciprocity) - Select "New Request (Reciprocity) when the contractor employee is new to the Office or Directorate and has the required investigative or Security Clearance for contract assignment and performance.

Position Change - Select “Position Change” when the duties of the contract position require a higher or lower level or access or risk (e.g., clearance upgrade/downgrade).

Contract Change - Select “Contract Change” if the contractor employee is changing contracts or is transferring from one Directorate to another.

Dual Contracts - Select “Dual Contract” if it is known in advance that the contractor employee is working on two or more contracts.

Name Change - Select “Name Change” if the contractor employee has legally changed their last name.

Exit Request - Select “Exit Request” if the contractor employee has left the contract position.

Please note that only those fields marked as (1) are required to be completed for an Exit request.

Section 1 - Requesting Official/Organization

Please complete all fields in Section I.

Section II - Individual to be Screened

Complete all fields in Section II.

Section III - Position Designation

Complete this section for positions associated with UNCLASSIFIED Contracts, or Classified contracts where the position requested does not require a Clearance. Only one risk level should be checked in either the Non-IT or IT Position area.

The following field definitions are provided to assist with the completion of this section:

Non-IT versus IT Positions

• Information Technology (IT) - Systems and services used in the automated acquisition, storage, manipulation, management, movement, control, display, switching, interchange, transmission, assurance, or reception of information. Information technology includes computers, network components, peripheral equipment, software, firmware, services, and related sources.

• Information Technology (IT) Position - Positions that manage, supervise, lead, administer, develop, deliver, or support information technology (IT) systems and services. Positions where the paramount requirement is knowledge of IT principles, concepts, and methods; e.g., data storage, software applications, and networking. (e.g., IT Worker)

• Non-Information Technology (IT) Position - Positions where the paramount requirement is the knowledge of other subject-matter principles, concepts, and methods. These positions may require the knowledge of the application of information technology to the assignment area or may require skill in use of IT software and hardware systems, but are not directly involved in development, delivering or supporting IT systems and services. (e.g., IT User)

Risk Levels

• Low Risk - Low Risk positions have the potential for limited impact on the integrity and efficiency of the service. These positions involve duties and responsibilities of limited relation to the agency or program mission.

o Please note that Low Risk is used for Building Access ONLY, where the position will not require access to FEMA systems or information.

• Moderate Risk (5N/5C) - Moderate Risk positions have the potential for moderate to serious impact on the integrity and efficiency of the service. These positions involve duties that are considerable important to the agency or program mission with significant program responsibility or delivery of service.

• High Risk (6N/6C) - High Risk positions have the potential for exceptionally serious impact on the integrity and efficiency of the service. These. These. These.These positions involve duties that are especially critical to the agency or the program mission with a broad scope of responsibility and authority.

Section IV - Position Security Clearance Requirements

Please complete this section for positions associated with CLASSIFIED Contracts. Please note that a DD-254 form is required for all contractor positions requiring a security clearance. By selecting “Yes” in the DD254 on File box below, you are verifying that a DD-254 is on file for the contract identified above. For positions not requiring a clearance, please indicate a Position Designation in Section III above.

Important: Classified positions requiring access to Special Compartmented Information (SCI) must be pre-approved by the Office Directorate SSO prior to sending to the FEMA Personnel Security Division.

Electronic Transmittal of FEMA Form Important: FEMA Personnel Security Division (PSD) will only accept FEMA Form 121-3-1-6, forms submitted by FEMA's COs, COTRs, or Federal Points of Contact (POCs). FEMA Form 121-3-1-6, Forms submitted by Contractor Employees or Contractor Company representatives will not be processed.

1. Complete FEMA Form, Contract Fitness/Security Screening Request;

2. Password Protected the File;

a.To Password Protect the File - Go to Tools - Options and click on the Security tab.

b.Under File Encryption Options for this Document - enter a password in the “Password to Open” box, and click OK; enter the same password in the Confirm Password dialog box.

c.Upon saving and closing the form, the password provided will be required to open.

3. Save the File using the following file naming convention: Applicant Last Name Request Date (MM/DD/YYYY) (Example:

Smith12042008.xls)

-OR-

Scan the completed FEMA Contract Fitness/Security Screening Request to a PDF file format. Using software such as Adobe Professional, Password Protected; and Save the File using the following naming convention: Applicant Last Name Request Date.pdf (Example: Smith12042008.pdf)

4. E-mail the file as an attachment to FEMA-OCSO-CONTRACTOR-COMPLIANCE-SECTION@FEMA.DHS.GOV a Subject line of “FEMA Directorate - FEMA Form, Contract Fitness/Security Screening Request - Date (Example: OPO - FEMA Form, Contract Fitness/Security Screening Request - 12/04/2008)

5. In a second e-mail to FEMA-OCSO-CONTRACTOR-COMPLIANCE-SECTION@FEMA.DHS.GOV using the same Subject line, send the password used to protect the information contained in the attachments.

Note: Please create or scan only one FEMA Form, Contract Fitness/Security Screening Request within a file attachment. If sending multiple attachments in a single e-mail message, please use the same password for all attachments contained within the message.

DISCLOSURE AND AUTHORIZATION

PERTAINING TO CONSUMER REPORTS

PURSUANT TO THE FAIR CREDIT REPORTING ACT

This is a release for the Department of Homeland Security to obtain one or more consumer/credit reports about you in connection with your application for employment or in the course of your employment with the Department. One or more reports about you may be obtained for employment purposes, including evaluating your fitness for employment, promotion, reassignment, retention, or access to classified information and/or sensitive, but unclassified information.

,hereby authorized the I, Department of Homeland Security to obtain such report(s) from any consumer/credit reporting agency for employment purposes. Copies of this authorization that show my signature are as valid as the original signed by me.

Signature

Date

Social Security Number

Organization Assigned

Street Address:_______________________________________________________________________

City:___________________________________________ State:_______ Zip Code :______________

Email Address: ______________________________________________________

The Privacy Act, 5 U.S.C. 552a, requires that federal agencies inform individuals, at the time information is solicited from them, whether the disclosure is mandatory or voluntary, by what authority such information is solicited, and what uses will be made of the information. You are hereby advised that authority for soliciting your Social Security Number (SSN) is Executive Order 9397. Your SSN will be used to identify you precisely when it is necessary to conduct and/or obtain a credit report on you. Although the disclosure of your SSN is not mandatory, your failure to do so may impede the acquisition of a credit report concerning you and possibly result in the denial of your being approved for access to classified and/or sensitive, but unclassified information.

DHS Form 11000-9 (10/08) (FEMA edit 2017)

NON-DISCLOSURE AGREEMENT

Protected Critical Infrastructure Information (PCII)

DHS Form 11000-6 (08-04)

Agreement in consideration of my being granted conditional access to certain information, specified below, that is owned by, produced by, or in the possession of the United States Government.

(Signer will acknowledge the category or categories of information that he or she may have access to, and the signer's willingness to comply with the standards for protection by placing his or her initials in front of the applicable category or categories.)

Initials:

I attest that I am familiar with, and I will comply with all requirements of the PCII program set out in the Critical Infrastructure Information Act of 2002 (CII Act) (Title II, Subtitle B, of the Homeland Security Act of 2002, Public Law 107-296, 196 Stat. 2135, 6 USC 101 et seq.), as amended, the implementing regulations thereto (6 CFR Part 29), as amended, and the applicable PCII Procedures Manual, as amended, and with any such requirements that may be officially communicated to me by the PCII Program Manager or the PCII Program Manager's designee.

Sensitive Security Information (SSI)Initials:

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of SSI information as cited in this Agreement and in accordance with 49 CFR Part 1520, "Protection of Sensitive Security Information," "Policies and Procedures for Safeguarding and Control of SSI," as amended, and any supplementary guidance issued by an authorized official of the Department of Homeland Security.

Other Sensitive but Unclassified (SBU)Initials:

As used in this Agreement, sensitive but unclassified information is an over-arching term that covers any information, not otherwise indicated above, 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 Section 552a of Title 5, as amended, 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. This includes information categorized by DHS or other government agencies as: For Official Use Only (FOUO); Official Use Only (OUO); Sensitive Homeland Security Information (SHSI); Limited Official Use (LOU); Law Enforcement Sensitive (LES);

Safeguarding Information (SGI); Unclassified Controlled Nuclear Information (UCNI); and any other identifier used by other government agencies to categorize information as sensitive but unclassified.

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of the information to which I am granted access as cited in this Agreement and in accordance with the guidance provided to me relative to the specific category of information.

I understand and agree to the following terms and conditions of my access to the information indicated above:

3. I attest that I understand my responsibilities and that I am familiar with and will comply with the standards for protecting such information that I may have access to in accordance with the terms of this Agreement and the laws, regulations, and/or directives applicable to the specific categories of information to which I am granted access. I understand that the United States Government may conduct inspections, at any time or place, for the purpose of ensuring compliance with the conditions for access, dissemination, handling and safeguarding information under this Agreement.

I, , an individual official, employee, consultant, or subcontractor of or to (the Authorized Entity), intending to be legally bound, hereby consent to the terms in this

1. I hereby acknowledge that I have received a security indoctrination concerning the nature and protection of information to which I have been provided conditional access, including the procedures to be followed in ascertaining whether other persons to whom I contemplate disclosing this information have been approved for access to it, and that I understand these procedures.

2. By being granted conditional access to the information indicated above, 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 and the laws, regulations, and directives applicable to the specific categories of information to which I am granted access.

8. If I violate the terms and conditions of this Agreement, such violation may result in the cancellation of my conditional access to the information covered by this Agreement. This may serve as a basis for denying me conditional access to other types of information, to include classified national security information.

4. I will not disclose or release any information provided to me pursuant to this Agreement without proper authority or authorization. Should situations arise that warrant the disclosure or release of such information I will do so only under approved circumstances and in accordance with the laws, regulations, or directives applicable to the specific categories of information. I will honor and comply with any and all dissemination restrictions cited or verbally relayed to me by the proper authority.

5. (a) For PCII - (1) Upon the completion of my engagement as an employee, consultant, or subcontractor under the contract, or the completion of my work on the PCII Program, whichever occurs first, I will surrender promptly to the PCII Program Manager or his designee, or to the appropriate PCII officer, PCII of any type whatsoever that is in my possession.

(2) If the Authorized Entity is a United States Government contractor performing services in support of the PCII Program, I will not request, obtain, maintain, or use PCII unless the PCII Program Manager or Program Manager's designee has first made in writing, with respect to the contractor, the certification as provided for in Section 29.8(c) of the implementing regulations to the CII Act, as amended.

(b) For SSI and SBU - I hereby agree that material which I have in my possession and containing information covered by this Agreement, will be handled and safeguarded in a manner that affords sufficient protection to prevent the unauthorized disclosure of or inadvertent access to such information, consistent with the laws, regulations, or directives applicable to the specific categories of information. I agree that I shall return all information to which I have had access or which is in my possession 1) upon demand by an authorized individual; and/or 2) upon the conclusion of my duties, association, or support to DHS; and/or 3) upon the determination that my official duties do not require further access to such information.

6. I hereby agree that I will not alter or remove markings, which indicate a category of information or require specific handling instructions, from any material I may come in contact with, in the case of SSI or SBU, unless such alteration or removal is consistent with the requirements set forth in the laws, regulations, or directives applicable to the specific category of information or, in the case of PCII, unless such alteration or removal is authorized by the PCII Program Manager or the PCII Program Manager's designee. I agree that if I use information from a sensitive document or other medium, I will carry forward any markings or other required restrictions to derivative products, and will protect them in the same matter as the original.

7. I hereby agree that I shall promptly report to the appropriate official, in accordance with the guidance issued for the applicable category of information, any loss, theft, misuse, misplacement, unauthorized disclosure, or other security violation, I have knowledge of and whether or not I am personally involved. I also understand that my anonymity will be kept to the extent possible when reporting security violations.

9. (a) With respect to SSI and SBU, 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 the information not consistent with the terms of this Agreement.

(b) With respect to PCII I hereby assign to the entity owning the PCII and the United States Government, all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of PCII not consistent with the terms of this Agreement.

10. This Agreement is made and intended for the benefit of the United States Government and may be enforced by the United States Government or the Authorized Entity. By granting me conditional access to information in this context, the United States Government and, with respect to PCII, the Authorized Entity, 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. I understand that if I violate the terms and conditions of this Agreement, I could be subjected to administrative, disciplinary, civil, or criminal action, as appropriate, under the laws, regulations, or directives applicable to the category of information involved and neither the United States Government nor the Authorized Entity have waived any statutory or common law evidentiary privileges or protections that they may assert in any administrative or court proceeding to protect any sensitive information to which I have been given conditional access under the terms of this Agreement.

DHS Form 11000-6 (08-04) Page 2

11. Unless and until I am released in writing by an authorized representative of the Department of Homeland Security (if permissible for the particular category of information), I understand that all conditions and obligations imposed upon me by this Agreement apply during the time that I am granted conditional access, and at all times thereafter.

12. 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.

13. My execution of this Agreement shall not nullify or affect in any manner any other secrecy or non-disclosure Agreement which I have executed or may execute with the United States Government or any of its departments or agencies.

14. These restrictions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by Executive Order No. 12958, as amended; 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 USC 421 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 USC 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.

15. Signing this Agreement does not bar disclosures to Congress or to an authorized official of an executive agency or the Department of Justice that are essential to reporting a substantial violation of law.

16. I represent and warrant that I have the authority to enter into this Agreement.

17. I have read this Agreement carefully and my questions, if any, have been answered. I acknowledge that the briefing officer has made available to me any laws, regulations, or directives referenced in this document so that I may read them at this time, if I so choose.

DHS Form 11000-6 (08-04)

DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE AGREEMENT

Acknowledgement Typed/Printed Name: Government/Department/Agency/Business Address Telephone Number:

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

Signature:

Typed/Printed Name: Government/Department/Agency/Business Address Telephone Number:

Signature:

WITNESS:

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

Date:

Date:

MOUNT WEATHER ACCESS APPLICATION

PLEASE READ THE INSTRUCTIONS AT THE BOTTOM BEFORE COMPLETING THIS FORM.

SECTION A –COMPLETED BY THE REQUESTING COMPONENT AND OFFICE

1. RESPONSIBLE COMPONENT AND OFFICE 2. GOVERNMENT SPONSOR (LAST, FIRST, MIDDLE) 3. SPONSOR PHONE NUMBER

4. SITE(S) TO BE ACCESSED BY INDIVIDUAL 5. FREQUENCY OF ACCESS (CHECK ONE)

DAILY WEEKLY MONTHLY OTHER

6. REASON FOR ACCESS:

7. SIGNATURE OF SPONSOR 8. LENGTH OF ACCESS REQUIREMENT

START DATE END DATE

9. GOVERNMENT INFORMATION

SYSTEMS ACCESS REQUIRED

YES NO

SECTION B – TO BE COMPLETED BY PRIMARY CONTRACTOR, if applicable

1. COMPANY / CONTRACTOR NAME 2. CONTRACT NUMBER 3. Signature 4. DATE

SECTION C – TO BE COMPLETED BY APPLICANT

1. FULL NAME (LAST, FIRST, MIDDLE) 2. SOCIAL SECURITY NUMBER 3. DATE OF BIRTH (MONTH/DAY/YEAR)

4. PLACE OF BIRTH (CITY, STATE, COUNTRY) 5. SEX

MALE

FEMALE

6. DRIVERS LICENSE # AND STATE

7. PRESENT ADDRESS (STREET ADDRESS, CITY, STATE, ZIP CODE) 8. CONTACT PHONE NUMBER

9. NAME AND ADDRESS OF EMPLOYER (Agency or Company) 10. OFFICE TELEPHONE

11. NAME OF SUPERVISOR & PHONE # 12. EMPLOYMENT STATUS

Federal Contractor Vendor Other_____________

13. DO YOU HOLD A U.S.CITIZENSHIP

STATUS?

YES NO

14. ARE YOU A NATURALIZED

CITIZEN?

YES NO

15. IF YES, Provide Naturalization Date and # IF Not a U.S. Citizen, Provide Alien Registration #

THIS RELEASE WHEN PRESENTED BY A DULY AUTHORIZED REPRESENTATIVE OF THE U.S. DEPARTMENT OF HOMELAND SECURITY (DHS) WILL CONSTITUTE MY CONSENT AND AUTHORITY TO EXAMINE AND OBTAIN COPIES AND ABSTRACTS OF RECORDS, AS WELL AS RECEIVE STATEMENTS OF INFORMATION CONCERNING MY BACKGROUND. SPECIFICALLY, I HEREBY AUTHORIZE THE RELEASE OF FEDERAL/STATE/LOCAL POLICE & CRIMINAL RECORDS TO DHS BY APPLYING MY SIGNATURE ON THE DESIGNATED LINE BELOW. THIS AUTHORIZATION IS GIVEN IN CONNECTION WITH THE INVESTIGATIVE PROCEDURES BEING CONDUCTED RELATIVE TO MY CONTRACTUAL SERVICES WITH THE DEPARTMENT OF HOMELAND SECURITY, AND/OR ACCESS TO SECURE AREAS

OCCUPIED BY THE DHS COMPONENTS.

PRIVACY ACT STATEMENT: ALL INFORMATION REQUESTED ON THE PERSONNEL ACCESS APPLICATION AND RELEASE STATEMENT IS COLLECTED UNDER AUTHORITY DERIVED FROM 18 USC 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. DEPARTMENT OF HOMELAND SECURITY. 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.

DEPARTMENT OF HOMELAND SECURITY. DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER IS VOLUNTARY. THE INFORMATION IS USED TO IDENTIFY AND SEPARATE INDIVIDUALS WITH SIMILAR OF 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.

NOTE: I UNDERSTAND THAT ANY FALSE STATEMENT ON ANY PART OF MY APPLICATION MAY BE GROUNDS FOR DENYING ME ACCESS INTO DEPARTMENT OF HOMELAND SECURITY CONTROLLED FACILITIES, AND/OR PROSECUTION UNDER TITLE18 USC 1001.

16. SIGNATURE OF APPLICANT 17. DATE

INSTRUCTIONS

1. Please type or print clearly with a dark ballpoint pen

2. To apply for access into FEMA/MWEOC controlled facilities, all applicants must complete this form in its entirety. (Failure to properly complete this form can result in contractual delays and/or non-admittance into facilities)

3. Section C must be completed and signed by individual applying for access. Form will then be returned to your Government Sponsor

4. The Government Sponsor must complete Section A, sign and forward form to: Mount Weather Security, fax 540-686-4399 or email (password protected) FEMA-MW-AreaA-Access@fema.dhs.gov

5. If there are any questions regarding this form, please telephone the office listed above at 540-542-2091/4383

For Internal Use Only

MWEOC Executive Administrator Office Division Director Supervisor

Approved Disapproved ________________________________ _____________ Signature Date

MW 05/2012

Page | 1

Agency Business Process for Access to Mt. Weather Emergency Operations Center

(MWEOC) As of Jan 1 2016

Area A Procedures – Normal Duty Hours

If a employee or contractor arrives to MWEOC and is initially unable to badge , they will be advised to proceed to building 911 for processing.

Upon reaching Access Control in building 911, the individual will be asked which agency/ comp they are with, who is sponsoring them and/or what building they are attempting to visit. The authorized sponsors fo are listed below:

1.

2.

c. Access Control will reach out to the named sponsor, confirming they are aware of the individual’s visit and will then require the individual to complete an Area A Access Request.

Once complete, the sponsor will need to sign the form.

Area A Procedures – After Duty Hours

If a employee or contractor arrives to MWEOC and is initially unable to badge onto , they will be advised to proceed to building 911 for processing.

Upon reaching building 911, the individual will be asked which agency/ they are with, who is sponsoring them and/or what building they are attempting to visit. The authorized sponsors for are listed below:

1.

2.

f. Access Officer will notify a MWPD Sergeant or above, which will reach out to the named sponsor, confirming they are aware of the individual’s visit and will then require the individual to complete an Area A Access Request. Once complete, access will be granted until the next business day. The access request and pertinent information will be e-mailed to MWEOC Access Control Office at FEMA-MW-AreaA-Access.

1. Federal Employees and contractors with government issued PIV credentials will be allowed unescorted access

2. Federal Employees and contractors without government issued PIV credentials will be granted escort required access

b. The next business day, the MW Access Control Office will ensure all appropriate paperwork is completed and update the access control system with the appropriate access and access dates. acquire the sponsor’s signature on the form and extend the applicant access until the requested date.

Mount Weather Emergency Operations Center Construction Contractor Cardholder Responsibility Agreement

MWEOC Construction Contractors must sign this cardholder responsibility agreement prior to being issued a MWEOC Construction Contractor Badge.

NOTE: MWEOC Construction Contractor Cardholders should be aware that they must adhere to FEMA’s reporting requirements related to compromised, lost, and stolen property.

NOTE: MWEOC Construction Contractor Cardholders will only use the search bay for vehicular access to MWEOC.

Pedestrian access will be through the visitor’s center turnstile.

As a MWEOC Construction Contractor Cardholder, I agree to the following:

1. I will use the MWEOC Construction Contractor Badge for official purposes only.

2. I will maintain control of my MWEOC Construction Contractor Badge at all times, and not allow anyone to use my MWEOC

Construction Contractor Badge for an unauthorized purpose. When not performing duties at my work site, I shall store my MWEOC Construction Contractor Badge out of plain sight.

3. I will not alter or otherwise deface my MWEOC Construction Contractor Badge. Altering or defacing includes punching a hole in, adhering decals to, or embossing the card.

4. I will report changes to my employee status (e.g., changing from one company to another) or a change in my name; or if my MWEOC Construction Contractor Badge is damaged. When this occurs, I will report these changes to my MWEOC Point of Contact (POC.)

5. I will report a lost or stolen card to a MWEOC security official or my MW POC so they can immediately disable the access on my card.

6. I understand that if I misuse the MWEOC Construction Contractor Badge issued to me, or it is compromised, lost, or stolen through my noncompliance with these requirements, I may be subject to administrative action.

7. I will surrender my MWEOC Construction Contractor Badge to the appropriate authority when my employment or association with MWEOC is terminated, or upon request by appropriate authority.

8. I will not violate Sections 499 and 701, Title 18 of the U.S. Code* through use of my MWEOC Construction Contractor Badge.

* 18 USC Sec. 499 says "Whoever falsely makes, forges, counterfeits, alters, or tampers with any naval, military, or official pass or permit, issued by or under the authority of the United States, or with intent to defraud uses or possesses any such pass or permit, or personates or falsely represents himself to be or not to be a person to whom such pass or permit has been duly issued, or willfully allows any other person to have or use any such pass or permit, issued for his use alone, shall be fined under this title or imprisoned not more than five years, or both."

* 18 USC Sec. 701 says "Whoever manufactures, sells, or possesses any badge, identification card, or other insignia, of the design prescribed by the head of any department or agency of the United States for use by any officer or employee thereof, or any colorable imitation thereof, or photograph, print, or in any other manner makes or executes any engraving, photograph, print, or impression in the likeness of any such badge, identification card, or other insignia, or any colorable imitation thereof, except as authorized under regulations made pursuant to law, shall be fined under this title or imprisoned not more than six months, or both.

MWEOC reserves the right to refuse to issue credentials to any person, and such decision may be made by MWEOC without notice and at its sole discretion. In addition, MWEOC may disable any credential at any time without notice.

By signing this agreement, I acknowledge my understanding and acceptance of the terms outlined in this agreement.

Printed Name Signature Date