A16PS01058_D5_BIA_EQIP_REQUEST_FORM.pdf

BIA eQip Request Form

For BIA Applicants, Employees, Contractors, or Tribal Users - FAX form to(505) 563-3039

IF REQUEST FORM IS NOT LEGIBLE OR INCOMPLETE, IT WILL NOT BE PROCESSED

FULL LEGAL NAME:

SOCIAL SECURITY NUMBER:

EMAIL ADDRESS:

DATE OF BIRTH:

CITY, STATE, COUNTRY OF BIRTH:

MOTOR VEHICLE OPERATION Regularly Occasionally Not Required

ACCOUNTING DATA

Fund: (i.e., 15X00000HT)

Cost Center: (i.e., AAK0000000)

Functional Area: (i.e., AM00PE0000.999900)

WBS: (i.e. AT.K0T00000.00000)

ORGANIZATIONAL CODE AND DIVISION, BRANCH OR AGENCY:

DUTY STATION (CITY/STATE):

SUPERVISOR NAME and GOV’T EMAIL ADDR:

NAME OF POINT OF CONTACT, HR REP, or COTR:

TELEPHONE AND FAX NUMBER:

Check One:

For Contractor/Volunteer provide the beginning and ending date. If IT access is required, provide the system (i.e., RIFDS, TAAMS, MAXIMO, etc.)

New Federal Employee Transfer Change in position Reinvestigation Tribal User (include system access below) Former Federal Employee (Date of Separation: __________________________) Contractor Volunteer: ____/____/____ to ____/____/____

Requires access to:_________________________________________

POSITION SENSITIVITY

RISK DESIGNATION

SECURITY CLEARANCE

REQUIRED

Non Sensitive Low Risk-Tier 1 (NACI) Non Sensitive Low Risk-Child Care (CNACI) Moderate Risk Public Trust-Tier 2 (MBI) High Risk Public Trust- BI Secret Clearance (Non-Critical Sensitive Position)-ANACI-P Top Secret Clearance (Critical Sensitive Position)-SSBI

Sponsored in DOIAccess (if incomplete, a background investigation cannot be initiated)

Yes Access Card required: Yes No

No-Contractor, Volunteer, Tribal User – contact your Federal agency point of contact. You must provide your complete home address (street address, city, state, zip code) Home Address:

Background Investigation Results – To be completed by the Personnel Security Office Record of Investigation:

Investigation Required:

Tier 1 (NACI) CNACI Tier 2 (MBI) NACLC

BI PRI

ANACI-P SSBI SSBI-PR

Forms Required: SF 85 SF 85P SF 86 OF 306 Declaration for Federal Employment Resume Applicant Screening Questionnaire Credit Release

Fingerprint Card: SF 87 FD 258 Date Initiated in eQIP:

Initiated By:

eQIP Request Number:

Favorable screening or adjudication notification issued by the personnel security office is required prior to an appointment to the position or recommendation for access

Federal Employee: Appointment to the Position Tribal User/Contractor/Volunteer: Access Recommended

Recommendation pending:

Revised June 2015