Attachment 12 - FLETC Tier 1 Badging Packet.pdf

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Jeong, Esther (CTR)

11.0.0.20130303.1.892433

DHS Form 11000-25

CONTRACTOR FITNESS / SECURITY SCREENING REQUEST FORM

Section II: Applicant Information

Please refer to the appended instructions when completing this form. Incomplete forms will be returned. This form must be submitted electronically to by the CO, COTR, or Federal POC.

Section I: Requesting Official/Organization

1.

Date of Submission

2.

DHS Organization

3.

Type of Request

4.

Exit Request Reason

5a.

CO:

Phone

DHS Email

5b. COTR/Federal POC:

Phone

DHS Email

6.

Prime Contractor

7. Prime Contract No.

8.

Task Order No.

9.

PIV Required

10.

DHS Organization Structure Code

11.

Applicant Name

12.

Position Title

13.

SSN

14.

Gender

15.

Place of Birth

16.

Date of Birth

17.

U.S. Citizen

18.

Phone

19. Email

Section III: Position Designation

20.

Position Risk Level

Section IV: Position Security Clearance Requirement

21.

Security Clearance Level

22.

DD254 on File

Privacy Act Information

Authority: 5 U.S.C. 5701-5733, Sections 5701-5733 and Executive Order 9397. Purpose: To facilitate the screening of applicants for contractor positions. Disclosure: Participation is voluntary; however, failure to provide this information may delay processing.

1 Indicates fields required for completing an Exit Request.

Last

First

Middle

City

State

Country (if not U.S.)

Name

Name

Last

First

Last

First

UNCLASSIFIED//FOR OFFICIAL USE ONLY

Complete this section for UNCLASSIFIED CONTRACTS ONLY. Note: Low Risk is used for Building Access ONLY, where the position will not require access to DHS systems or information.

Complete this section for CLASSIFIED CONTRACTS ONLY. Note: A DD254 form is required for all contractor positions requiring a security clearance, and should be on file with ISPB.

DEPARTMENT OF HOMELAND SECURITY

CONTRACTOR FITNESS/SECURITY SCREENING REQUEST FORM

DHS Form 11000-25 (7/17)

Instructions - Completing DHS Form 11000.25, Contractor Fitness/Security Screening Request

General

The DHS form 11000.25, Contractor Fitness/Security Screening Request is used by DHS federal employees to request that the Office of Security, Personnel Security Division (PSD) perform the appropriate fitness screening on contract employees based on the risk levels of their positions. 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 DHS operations. When determining risk levels, program officials may compare the individual’s duties, responsibilities, and access with those of DHS 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 Tier-2 investigation conducted within the last 5 years. If, during the fitness process, it is determined that the individual has been investigated by another Federal agency, DHS will use the investigation(s) whenever practical. However, if the investigation is out of date or not at the required level for the position, DHS will need to initiate a new background investigation and incur the costs associated with the investigation. Therefore, it is extremely important that the appropriate position designation be made on the initial request to avoid the additional cost and time associated with position changes that may require higher level investigations.

On Classified Contracts, a few or all of the positions may require access to national security information (NSI). In this case, the contract employee must have an active clearance at, or higher than, the level designated by the DHS position. Please note that DHS does not grant security clearances to contract employees.

Contract Employee Clearances - DHS recognizes contract employee clearance levels based on the risk or access level designated to the DHS contract position. For example, a contract employee may be eligible through his company and the Department of Defense Consolidated Adjudications Facility (DoD CAF) for access at the Top Secret level; however, if the DHS 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 DHS position is designated as a Public Trust position (i.e., unclassified contracts – low through high risk), then the position and associated PIV card or badge is marked with no security clearance. In other words, the security clearance level is to be associated with the position, and not the individual.

Section I: Requesting Official/Organization

Please complete all fields in Section I.

For 3. Type of Request, select one of the following request types:

Contract Change – Select if the contract employee is changing contracts or is transferring from one Directorate to another.

w

Exit Request – Select if the contract employee has left the contract position.

Please note that only those fields marked with 1 are required to be completed for an Exit Request.

o w w w w w w w

Multiple Contracts – Select if it is known in advance that the contract employee is working on two or more contracts.

Name Change – Select if the contract employee has legally changed his/her last name.

New Request – Select if the contract employee is new to the Office or Directorate.

Position Change – Select if the duties of the contract position require a higher or lower level of access or risk (e.g., clearance upgrade/downgrade; TECS access upgrade/downgrade).

Reinvestigation – Select if one of the following conditions apply:

a.

Contract employee has an investigation that was completed after the date of submission of the last 11000.25 form.

Important: If there is an investigation that was recently updated, the submitter of the current 11000.25 form must provide proof of the completed investigation.

b.

Contract employee requires an updated investigation to be initiated by the Security Office.

Temporary Position – Select if the contract employee will be on the contract for 180 days or less.

DHS Form 11000-25 (7/17)

Instructions - Completing DHS Form 11000.25, Contractor Fitness/Security Screening Request

The following definition is provided to assist with the completion of this section:

DHS Organization Structure Code – The DHS Organization Structure Code is the 18-digit code used by DHS to identify the Division sponsoring the request. If you are not sure of the code for your organization, please contact your Human Resource Liaison.

Section II: Applicant Information

Please complete all fields in Section II.

Section III: Position Designation

Please 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 selected in either the Non-IT or IT Position category.

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 (N) – 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 DHS 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 of considerable importance 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 positions involve duties that are especially critical to the agency or the program mission with a broad scope of responsibility and authority.

DHS Form 11000-25 (7/17)

Section IV: Position Security Clearance Requirement

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, and must be on file with the DHS Industrial Security Program Branch (ISPB). For positions not requiring a clearance, please indicate a Position Designation in Section III above.

Important: By selecting the DD254 on File checkbox, you are verifying that a DD-254 is on file for the contract identified above. To verify DD254 information, please contact DD254administrativesecurity@hq.dhs.gov.

Instructions - Completing DHS Form 11000.25, Contractor Fitness/Security Screening Request

Electronic Transmittal of DHS Form 11000.25

Important: DHS Personnel Security Division (PSD) will only accept DHS 11000.25 forms submitted by DHS Contracting Officer Representatives (CORs) or Federal Points of Contact (POCs). DHS 11000.25 forms submitted electronically by Contract Employees or Contractor Company representatives will not be processed.

1)

Complete the DHS Form 11000.25, Contractor Fitness/Security Screening Request;

2)

Scan the file (if applicable);

3)

Password-Protect the File;

a.

To password-protect the file, go to Tools – Protect & Standardize and click on the Protect icon.

b.

Expand the Encrypt dropdown at the top of the screen, and select the Encrypt with Password option. In the resulting pop-up window (“Are you sure you want to change the security on this document?”), select Yes.

c.

Select the checkbox next to the Require a password to open the document option towards the top of the window – enter a password in the Document Open Password text field, and click OK. In the resulting confirmation window, re-enter the password and click OK.

d.

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

4)

Save the file using the following file-naming convention: ApplicantLastNameRequestDate (MM/DD/YYYY) (e.g., Smith12042008.pdf)

5)

Email the file as an attachment to with a Subject line of "DHS Directorate – 11000.25 Request – Date” (e.g., OPO – 11000.25 Request – 11/20/2008).

6)

In a second email to the Office of Security using the same Subject line, send the password used to protect the information contained in the attachments.

Note: Please create or scan only one DHS form 11000.25 within a file attachment. If sending multiple attachments in a single email message, please use the same password for all attachments contained within the message.

DHS Form 11000-25 (7/17)

Please refer to the appended instructions when completing this form. Incomplete forms will be returned. This form must be submitted electronically to by the Contracting Officer, Contracting Officer's Technical Representative, or Federal point of contact. Select from list.: Select

Section 1. Requesting Official / Organization. 1. Date of Submission. Enter 2 digit month, 2 digit day and 4 digit year. Field required for completing an Exit Request.:

2. D H S Organization. Field required for completing an Exit Request.: Select

3. Type of Request.: Select

4. Exit Request Reason. Field required for completing an Exit Request.: None

5. A. Contract Officer. Last Name. Field required for completing an Exit Request.:

5. A. Contract Officer. First Name.:

5. A. Contract Officer. Phone Number.:

5. A. Contract Officer. D H S Email Address. Field required for completing an Exit Request. Field required for completing an Exit Request.:

5b. Contracting Officer's Technical Representative / Federal Point of Contact. Last Name. Field required for completing an Exit Request.:

5b. Contracting Officer's Technical Representative / Federal Point of Contact. First Name. Field required for completing an Exit Request.:

5b. Contracting Officer's Technical Representative / Federal Point of Contact. Phone Number.:

5b. Contracting Officer's Technical Representative / Federal Point of Contact. D H S Email. Field required for completing an Exit Request.:

6. Prime Contractor.:

7. Prime Contract Number.:

8. Task Order Number.:

9. PIV Required. Select from list.: Select

10. D H S Organization Structure Code.:

Section 2. Applicant Information. 11. Applicant Last Name. Field required for completing an Exit Request.:

11. Applicant First Name. Field required for completing an Exit Request.:

11. Applicant Middle Name. Field required for completing an Exit Request.:

12. Position Title. Field required for completing an Exit Request.:

13. Social Security Number. Field required for completing an Exit Request.:

14. Gender. Select from list.: Select

15. Place of Birth. City.:

15. Place of Birth. State. Select State from list.: Select

15. Place of Birth. Country (if not U. S.) Select from list.: Select

16. Date of Birth. Enter 2 digit month, 2 digit day and 4 digit year.:

17. U.S. Citizen.: Off

18. Phone Number.:

19. Email.:

Section 3. Position Designation. Complete this section for UNCLASSIFIED CONTRACTS ONLY. Note. Low Risk is used for Building Access ONLY, where the position will not require access to D H S systems or information. 20. Position Risk Level. Select from list.: Select

Section 4. Position Security Clearance Requirement. Complete this section for CLASSIFIED CONTRACTS ONLY. Note: A D D 2 54 form is required for all contractor positions requiring a security clearance, and should be on file with I S P B. 21. Security Clearance Level. Select from list. : Select

22. D D 2 54 on File.: Off

5. Email the file as an attachment to. Select from list.: Select

Declaration for Federal Employment* (*This form may also be used to assess fitness for federal contract employment)

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management 5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2011

Previous editions obsolete and unusable

Instructions

The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. You may be asked to complete this form at any time during the hiring process. Follow instructions that the agency provides. If you are selected, before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").

Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement

The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement

Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

GENERAL INFORMATION

1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER

3a. PLACE OF BIRTH (Include city and state or country)

3b. ARE YOU A U.S. CITIZEN?

YES NO (If "NO", provide country of citizenship) ♦

4. DATE OF BIRTH (MM / DD / YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc)

6. PHONE NUMBERS (Include area codes)

Day ♦ Night ♦

Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Are you a male born after December 31, 1959? YES NO (If "NO", proceed to 8.)

7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) in item 16.

Military Service

8. Have you ever served in the United States military? YES (If "YES", provide information below) NO

If you answered "YES," list the branch, dates, and type of discharge for all active duty.

If your only active duty was training in the Reserves or National Guard, answer "NO."

Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge

Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?

(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

YES NO

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

Additional Questions

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?

(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law,mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, and half sister.) If "YES," use item 16 to provide the relative's name,relationship, and the department, agency, or branch of the Armed Forces for which your relative works.

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

Continuation Space / Agency Optional Questions

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).

Certifications / Additional Questions APPLICANT: If you are applying for a position and have not yet been selected, carefully review your answers on this form and any attached sheets. When this form and all attached materials are accurate, read item 17, and complete 17a.

APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions.

When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith . I understand that a false or fraudulent answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.

17a. Applicant's Signature: Date (Sign in ink)

17b. Appointee's Signature: Date (Sign in ink)

Appointing Officer:

Enter Date of Appointment or Conversion

MM / DD / YYYY

18. Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? DATE:

MM / DD / YYYY

18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?

YES NO DO NOT KNOW

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

YES NO DO NOT KNOW

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306

Revised October 2011

Previous editions obsolete and unusable

Optional Form 306 (Rev. October 2011)

Declaration for Federal Employment (This form may also be used to assess fitness for federal contract employment)

U.S. Office of Personnel Management

Instructions

The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. You may be asked to complete this form at any time during the hiring process. Follow instructions that the agency provides. If you are selected, before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11"). Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement

The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement

Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

GENERAL INFORMATION

1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER

3a. PLACE OF BIRTH (Include city and state or country)

3b. ARE YOU A U.S. CITIZEN?

4. DATE OF BIRTH (MM / DD / YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc)

6. PHONE NUMBERS (Include area codes)

Day ♦

Night ♦

Selective Service Registration

If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Are you a male born after December 31, 1959?

7b. Have you registered with the Selective Service System?

7c. If "NO," describe your reason(s) in item 16.

Military Service

8. Have you ever served in the United States military?

If you answered "YES," list the branch, dates, and type of discharge for all active duty.

If your only active duty was training in the Reserves or National Guard, answer "NO."

Branch

From (MM/DD/YYYY)

To (MM/DD/YYYY)

Type of Discharge

Background Information

For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole? (Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

Additional Questions

14. Do any of your relatives work for the agency or government organization to which you are submitting this form? (Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law,mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, and half sister.) If "YES," use item 16 to provide the relative's name,relationship, and the department, agency, or branch of the Armed Forces for which your relative works.

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

Continuation Space / Agency Optional Questions

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).

Certifications / Additional Questions

APPLICANT: If you are applying for a position and have not yet been selected, carefully review your answers on this form and any attached sheets. When this form and all attached materials are accurate, read item 17, and complete 17a.

APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions. When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith . I understand that a false or fraudulent answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.

17a. Applicant's Signature:

Date

(Sign in ink)

17b. Appointee's Signature:

Date

(Sign in ink)

Appointing Officer:

Enter Date of Appointment or Conversion MM / DD / YYYY

18. Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job?

MM / DD / YYYY

18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

fullName:

ssn:

placeBirth:

q3bYes: 0 q3bNo: 0 q3bSpecify:

dateBirth:

q5Answer1:

q5Answer2:

dayPhone:

nightPhone:

q7aYes: 0 q7aNo: 0 q7bYes: 0 q7bNo: 0 q8Yes: 0 q8No: 0 branchLine1:

fromDateLine1:

toDateLine1:

typeDischargeLine1:

branchLine2:

fromDateLine2:

toDateLine2:

typeDischargeLine2:

branchLine3:

fromDateLine3:

toDateLine3:

typeDischargeLine3:

q9Yes: 0 q9No: 0 q10Yes: 0 q10No: 0 q11Yes: 0 q11No: 0 q12Yes: 0 q12No: 0 q13Yes: 0 q13No: 0 q14Yes: 0 q14No: 0 q15Yes: 0 q15No: 0 q16Specify:

q18aDate:

q18bYes: 0 q18bNo: 0 q18bDNK: 0 q18cYes: 0 q18cNo: 0 q18cDNK: 0 viewer may not be able to display this type of document.

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DHS FORM 11055 (06/17)

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INSTRUCTIONS

Requestors shall forward this form to the foreign national(s) being considered for screening. One form may include multiple individuals for the same visit or event by clicking the Add Individual button. Once the foreign national completes the Foreign National Information section, return the form to the Requestor. All fields are mandatory. Failure to complete all the fields may result in a processing delay.

FOREIGN NATIONAL INFORMATION

LAST NAME:

FIRST NAME:

MIDDLE NAME:

ALIASES:

VISITOR TYPE:

GENDER:

DATE OF BIRTH (MM/DD/YYYY):

CITY AND COUNTRY OF ORIGIN:

DUAL CITIZENSHIP:

LEGAL PERMANENT RESIDENT:

COUNTRY(IES) OF CITIZENSHIP:

CITY AND COUNTRY OF RESIDENCE:

PASSPORT COUNTRY OF ISSUE:

PASSPORT NUMBER:

EXPIRATION DATE (MM/DD/YYYY):

VISA ISSUANCE LOCATION:

VISA TYPE:

VISA NUMBER:

VISA EXPIRATION DATE (MM/DD/YYYY):

ALIEN REGISTRATION NUMBER (LPR):

CURRENT EMPLOYER (COUNTRY OR COMPANY):

EMPLOYER TELEPHONE NUMBER:

GOVERNMENT OWNED BUSINESS:

CURRENT EMPLOYER (COUNTRY OR COMPANY ADDRESS (STREET, CITY, STATE, ZIP CODE, COUNTRY)):

TYPE OF BUSINESS OR ORGANIZATION:

JOB TITLE OR POSITION:

CONTACT NUMBER:

EMAIL ADDRESS:

SPONSOR INFORMATION (For Internal Use Only)

NAME (LAST, FIRST, MIDDLE):

JOB TITLE OR POSITION:

DATE OF REQUEST (MM/DD/YYYY):

COMPONENT:

OFFICE OR PROGRAM:

EMAIL ADDRESS:

TELEPHONE NUMBER:

VISIT OR EVENT INFORMATION (For Internal Use Only)

TYPE OF VISIT/EVENT:

AFFECTED PROGRAM:

DATE(S) OF VISIT OR EVENT:

CLASSIFICATION OF ACCESS:

DISCLOSURE OF INFORMATION:

NAME AND TITLE OF VISIT HOST OR AFFECTED FEDERAL EMPLOYEE:

HOST ORGANIZATION:

PURPOSE OF REQUEST:

HOST TELEPHONE NUMBER:

LOCATION OF ACCESS:

HOST EMAIL ADDRESS:

BACKGROUND (DESCRIBE THE CIRCUMSTANCES SURROUNDING THE SCREENING REQUEST)

PRIVACY ACT STATEMENT

Authority: The collection of this information is authorized by 6 U.S.C. § 341 (2010); Security Executive Agent (SecEA) Directive (SEAD) 3; DHS Policy Directive 121-11, Foreign Access Management; and DHS MD 11052, Internal Security Program.

Purpose: DHS will use this form to screen a foreign national and determine if he or she should be granted access to DHS information, personnel, systems, and facilities.

Routine Uses: The information will be used by and disclosed to DHS Security personnel, contractor employees, or other agents responsible for evaluating foreign nationals who request access to DHS. DHS may share the information when appropriate and permissible under a routine use in the DHS/ALL/PIA-048(a) Foreign Access Management System (FAMS) and the DHS/ALL-024 Department of Homeland Security Facility and Perimeter Access Control and Visitor Management System of Records Notice, 75 FR 5609 (February 3, 2010).

Disclosure: Providing the requested information is voluntary, but failure to do so could result in the denial of the foreign national’s access to DHS information, personnel, systems, and facilities.

10.0.2.20120224.1.869952.867557

NAME (LAST, FIRST, MIDDLE).:

NAME (LAST, FIRST, MIDDLE).:

NAME (LAST, FIRST, MIDDLE).:

ALIASES.:

TYPE OF VISIT/EVENT.:

GENDER.:

DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.:

CITY AND COUNTRY OF ORIGIN.:

YES:

NO:

COUNTRY(IES) OF CITIZENSHIP.:

CITY AND COUNTRY OF RESIDENCE.:

PASSPORT COUNTRY OF ISSUE (MANDATORY).:

PASSPORT NUMBER (MANDATORY).:

EXPIRATION DATE (MANDATORY). Enter 2 digit month, 2 digit day and 4 digit year.:

VISA ISSUANCE LOCATION.:

VISA TYPE.:

VISA NUMBER.:

VISA EXPIRATION DATE. Enter 2 digit month, 2 digit day and 4 digit year.:

ALIEN REGISTRATION NUMBER.:

CURRENT EMPLOYER (COUNTRY OR COMPANY).:

EMPLOYER TELEPHONE NUMBER. Enter 10 digit telephone number including area code.:

CURRENT EMPLOYER (COUNTRY OR COMPANY ADDRESS (STREET, CITY, STATE, ZIP CODE, COUNTRY).:

TYPE OF BUSINESS OR ORGANIZATION.:

JOB TITLE OR POSITION.:

CONTACT NUMBER. Enter 10 digit telephone number including area code.:

EMAIL ADDRESS.:

ADD INDIVIDUAL. Add additional foreign nationals for screening.:

REMOVE INDIVIDUAL. Remove last set of foreign national data.:

NAME (LAST, FIRST, MIDDLE).:

JOB TITLE OR POSITION.:

DATE OF REQUEST. Enter 2 digit month, 2 digit day and 4 digit year.:

ORGANIZATION:

OFFICE OR PROGRAM.:

TELEPHONE NUMBER. Enter 10 digit telephone number including area code.:

TYPE OF VISIT/EVENT.:

AFFECTED PROGRAM.:

DATE(S) OF VISIT OR EVENT.:

CLASSIFICATION OF ACCESS.:

NAME AND TITLE OF VISIT HOST OR AFFECTED FEDERAL EMPLOYEE.:

HOST ORGANIZATION.:

PURPOSE OF REQUEST.:

HOST TELEPHONE NUMBER. Enter 10 digit telephone number including area code.:

LOCATION OF ACCESS.:

HOST EMAIL ADDRESS.:

BACKGROUND (DESCRIBE THE CIRCUMSTANCES SURROUNDING THE SCREENING REQUEST).:

EMAILSUBMIT:

DEPARTMENT OF HOMELAND SECURITY

DISCLOSURE AND AUTHORIZATION

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.

I, authorized the 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

Current Organization Assigned

DHS Form 11000-9 (10/08)

, hereby

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.

PERTAINING TO CONSUMER REPORTS

PURSUANT TO THE FAIR CREDIT REPORTING ACT

Microsoft Word - DHS Form 11000- 9.doc mwilson

D:20050907125339- 04'00'

D:20050907125339- 04'00'

DISCLOSURE AND AUTHORIZATION

This is a release for the…