Attachment 12 - Contractor Investigative Request (CIR).pdf

CONTRACTOR INVESTIGATIVE REQUEST

NAME: ____________________________________________ SSN: _________________________ Last Name, First Name MI

DOB: ________________ City/State OR City/Country of Birth:________________________________

DLA Distribution Site / DLA Distribution Directorate:_______________________________________

CONTRACT NUMBER:_______________________ COMPANY NAME:___________________________

The above named contractor requires the following designation in accordance with DLAI 8500.1 and DLAI 4314:

___ IT I

___ IT II

___ IT III

*Note: Clearances required for access to classified material and/or information are requested through the Contractor’s Cognizant Security Agency (CSA) and granted by the DoD Consolidated Adjudications Facility (DoD CAF), Industry Division.

REQUESTING OFFICIAL DATE

VALIDATION OF REQUEST

TO: _________________ FROM: DLA Intelligence (New Cumberland)

____ The requested determination has been processed and all necessary investigative requirements have been met.

Type Investigation Completed: ___________________ Eligibility Level: ____________________

Investigation Completion Date: ___________________ Date Granted: ____________________

____ Unfavorable determination has been made. Access eligibility is denied.

DI SECURITY SPECIALIST

DATE

Revision - September 2016

___ Installation Access Only

___ Secret Clearance*

___ Other: _______________

___ Child Care

___ AA & E Storage

___ ESS Maintenance

SP3300-20-R-0002

Attachment 12 - CIR