Attachment 3 - DLAH 1728.pdf

REQUEST FOR HQC CONTRACTOR BADGE AND/OR INFORMATION TECHNOLOGY (IT) ACCESS

11. INDICATE ACCESS LEVEL

4. DATE OF BIRTH

19. SIGNATURE OF PERSONNEL SECURITY SPECIALIST

(1) NAC / NACI / PRS

(2) NACLC

(3) SSBI / SBPR

16. CONTRACTOR

DLAH FORM 1728, OCT 2004 (EG)

PART I - TO BE COMPLETED BY SPONSOR/CONTRACTOR

IT Contractors must meet the security requirements in accordance with DoD Directive 8500.1, Information Assurance; DoD 5200.2-R and DLAR 5200.11, Personnel Security Program security requirements. IT I contractors must have a favorable Single Scope Background Investigation (SSBI), IT II must have a favorable National Agency Check with Law and Credit Checks (NACLC), and IT III contractors must have a favorable National Agency Check (NAC). ALL OTHER CONTRACTORS MUST HAVE A FAVORABLE NAC FOR BUILDING ACCESS. Contractors must frequent the HQC a minimum of 3 times per week to be eligible for a badge.

1. NAME (Last, First, MI) 2. SSN 3. DATE OF REQUEST

6. EYE COLOR 7. HAIR COLOR 8. HEIGHT5. PLACE OF BIRTH

9. COMPANY NAME 10. CONTRACTING ACTIVITY/SPONSOR

13. DATE CONTRACT EXPIRES (MMDDYYYY)12. CONTRACT NUMBER

14. REASON FOR ISSUANCE ("X" appropriate block)

a. INITIAL ISSUE b. RENEWAL (Expired badge must be turned in.) c. LOST

d. STOLEN e. DESTROYED f. NAME CHANGE (Documentation required. Old badge must be turned in.)

NOTE: Clearances required for access to classified material and/or information are to be requested through the Contractor's Cognizant Security Agency (CSA) and granted by the Defense Industrial Security Clearance Office (DISCO).

a. SIGNATURE OF CONTRACTOR c. TELEPHONE NUMBER

17. SPONSOR

a. NAME

e. TELEPHONE NUMBER

b. ACTIVITY

c. SIGNATURE

PART II - TO BE COMPLETED BY SECURITY

18.a. TYPE OF INVESTIGATION 20.a. BADGE NO:

b. ISSUE DATE:

c. EXPIRATION DATE (4 months for an initiated investigation, and length of contract (NTE 1 year) for completed investigation):

21. SIGNATURE OF ISSUING OFFICIAL

b. DATE INITIATED c. DATE COMPLETED

b. DATE SIGNED

d. DATE SIGNED

PDF (DLA)

DATE SIGNED DATE SIGNED

15a. IS ACCESS TO CLASSIFIED INFORMATION REQUIRED?

YES NO

15b. LEVEL OF ACCESS REQUIRED:

TOP SECRET SECRET CONFIDENTIAL

10 U.S.C. 133, Under Secretary of Defense for Acquisition and Technology; E.O. 9397 (SSN); E.O. 10450 (Security Requirements for Government Employees); and DLA Privacy Act System Notice S500.50, available at http://www.defenselink.mil/privacy/notices/dla/.

Information is collected to allow us to issue you a building badge. The badge is used to control access to and movement on DLA installations, buildings, or facilities.

Information you provide may be disclosed for any of the Routine Uses published by DoD at http://www.defenselink.mil/privacy/notices/blanket-uses.html Contact the system manager or your local Privacy Act Officer for further details.

Disclosure is voluntary. However, failure to provide the requested information will result in our inability to issue you a badge or grant you access to DLA installations, buildings, or facilities.

AUTHORITY:

PRINCIPAL PURPOSE(S):

ROUTINE USES:

DISCLOSURE:

UEIT I IT II IT III

18.d. CITIZENSHIP

U.S. NON - U.S. DUAL CITIZEN

d. EMAIL ADDRESS

f. EMAIL ADDRESS

PRIVACY ACT DATA

http://www.defenselink.mil/privacy/notices/dla/ http://www.defenselink.mil/privacy/notices/blanket-uses.html