Attachment 3 - (SAMPLE) United States Mint Security Clearance Package.pdf

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UNITED STATES MINT SECURITY PACKAGE CHECKLIST

The attached security package must be completed in full before submission to the U.S. Mint. Contractor (new hire) and Contract Specialist/COTR must initial each item listed below before the security package may be submitted. This is confirmation that each item is included in the security package and is complete.

Contractor Contract Specialist/COTR

Checklist ________

PIV Request Form ________

Request for Pre-Appointment Investigation (Mint 5009) ________

Fair Credit Report Act (FCRA) Form (TD F 15-03.9) ________

Declaration for Federal Employment (OF 306, Oct 2011) ________

Non-Disclosure Agreement ________

Naturalization Paperwork (Current U.S. Passport in lieu of) ________

Other (____________________________________) ________

United Stated Mint

PIV REQUEST

Request for: Employee: ____ Contractor: ____ (Length of Contract): less < 180 days____ or greater >180 days____ Section 1: Applicant Information (To be filled out by the Sponsor)

Last Name, First Name, M.I.: ____________________________________________________ SSN: ______________________

DOB:___________ POB:_________________ Contact Phone #: ________________ Email: _________________________

(At agency discretion the following optional information may be requested)

Eye Color: ____________ Hair Color: ____________ Height: _________ Weight: _________

Former Employee/Contractor: Yes______No_________ Office/Company Name ______________________________________

Mailing Address: _________________________________________________________________________________________

Applicant: I agree to participate in the PIV process.

(Applicant Signature & Date) ________________________________________ Date____________________

Sponsor: I agree to sponsor the above applicant for a PIV credential.

(Sponsor Name, Title, Signature, Date) _________________ Title__________________ Sign.______________ Date_______

COR Name:_______________________________ Office_____________________ Work Number_______________

Section 2: Registrar

A. Identity Verification

ID #1 ID #2

ID Type/Title: ______________________ ID Type/Title: _____________________________ ID Number: ________________________ ID Number: _______________________________ ID Exp. Date: ______________________ ID Exp. Date: ______________________________ (At least one ID must be a valid State or Federal Issued photo ID. Note: Current Federal ID badges will not be accepted)

I certify that the information is accurate to the best of my knowledge.

(Registrar Name, Title, Signature, Date) _________________ Title__________________ Sign.______________ Date_______

B. Background Investigation (If Applicable) FBI Criminal Check (NCIC and SAC): Initiated: _________________ Completed: _______________________

(If Applicable) Initial Suitability Adjudicated: Favorably: _____________ Unfavorably: ______________

Background Investigation Initiated Date: ______________________ (If applicable for Registrar section) Card Stock Control Number: ______________________ (If applicable for Registrar section) Date Background Investigation Completed: _____________________

(If applicable for Registrar section) Suitability Adjudicated: Favorably: ___________ Unfavorably: ___________

I certify that the above information is accurate to the best of my knowledge.

(Registrar Name, Title, Signature, Date) _________________ Title__________________ Sign.______________ Date_______

Section 3: Issuer Part A.

Applicant identity re-verified: __________ (If Applicable) Interim (NC) Credential Issued Date: ____________________

I acknowledge issuance of a credential to the applicant identified above based on verification of the applicant’s identity and verification of the above Registrar’s issuance approval. I certify that the above information is accurate to the best of my knowledge.

(Issuer Name, Title, Signature, Date) _________________ Title__________________ Sign.______________ Date_______

The Department of the Treasury

PIV REQUEST FORM

Part B.

(If applicable for Issuer section) (If applicable for Issuer section) Date Background Investigation Completed: ____________ Suitability Adjudicated: Favorably: _____ Unfavorably: _____

Permanent PIV Card Issued Date: ______________________ (If applicable for Issuer section) Card Stock Control Number: ______________________ Permanent PIV Card Expiration Date: ______________________

I acknowledge issuance of a credential to the applicant identified above based on a favorably adjudicated background investigation.

(Issuer Name, Title, Signature, Date) _________________ Title__________________ Sign.______________ Date_______

Section 4: Applicant Acknowledgement

Part A (When applicable this is to be signed by applicant after issuance of interim credential) I, the Applicant, confirm receipt of the PIV credential and that the information is accurate to the best of my knowledge, and agree to abide by all rules and responsibilities associated with this credential and the PIV process to include the following:

May not attempt to copy, modify or obtain data from any PIV Card, may not assist others in gaining unauthorized access to Federal facilities or information, and must report the loss or theft of an issued PIV Card within 24 hours.

Applicant Signature _____________________________ Date _________________________

Part B (This is to be signed by applicant after issuance of permanent credential) I, the Applicant, confirm receipt of the PIV credential and that the information is accurate to the best of my knowledge, and agree to abide by all rules and responsibilities associated with this credential and the PIV process to include the following:

May not attempt to copy, modify or obtain data from any PIV Card, may not assist others in gaining unauthorized access to Federal facilities or information, and must report the loss or theft of an issued PIV Card within 24 hours.

Applicant Signature _____________________________ Date __________________________

PRIVACY ACT INFORMATION

Authority: 5 U.S.C. 301; Federal Information Security Management Act (Pub. L. 107-296, Sec. 3544); E-Government Act (Pub. L. 107-347, Sec. 203); Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) and Government Paperwork Elimination Act (Pub. L. 105-277, 44 U.S.C. 3504); Homeland Security Presidential Directive 12 (HSPD-12), Policy for a Common Identification Standard for Federal Employees and Contractors, August 27, 2004.

Purpose: In connection with evaluating an applicant to determine whether the applicant should be provided with a PIV credential, the primary purposes of the information collected on this form are: to ensure the safety and security of Federal facilities, systems, or information, and of facility occupants and users; to provide for interoperability and trust in allowing physical access to individuals entering Federal facilities; and to allow logical access to Federal information systems, networks, and resources on a government-wide basis.

Uses: In addition to disclosures permitted by the Privacy Act, information collected by this form may be shared with federal and other government agencies and individuals, including the U.S. Department of Justice, Office of Personnel Management, and the Federal Bureau of Investigation, for purposes including evaluation of federal personnel and FBI National Criminal History checks. For additional information and details on how this information may be used and who may see it, please see the most recently published System of Record Notice for the government-wide system HSPD-12 USAccess (GSA-GOVT-7).

A PIV credential is a requirement for access to United States Mint computer systems, and for non-guest access to United States Mint facilities. While the public generally does not have to apply for a PIV credential or provide the credential applicant information requested on this form, if you do not apply for a PIV credential and provide all of the applicant information requested by this form, you will not be able to receive a PIV credential, and may not be able to perform duties and activities that require PIV credentials, which may affect your employment or contractor status.

DEPARTMENT OF THE TREASURY MF5023

United States Mint (Revised 8/1/2017)

Request for: Employee: ____ Contractor: ____ (Length of Contract): less < 180 days____ or greater >180 days____

Section 2: Registrar

B. Background Investigation

Section 3: Issuer

Last Name First Name MI:

SSN:

DOB:

POB:

Contact Phone:

Email:

Weight:

OfficeCompany Name:

Mailing Address:

Title:

COR Name 1:

Office:

Work Number:

ID TypeTitle:

ID TypeTitle_2:

ID Number:

ID Number_2:

Title_2:

Card Stock Control Number:

Title_3:

Applicant identity reverified:

Title_4:

Card Stock Control Number_2:

Title_5:

Check Box1: Off

Check Box2: Off

Check Box3: Off

Check Box4: Off

Dropdown5: [select]

Dropdown6: [select]

Dropdown7: [select]

Check Box8: Off

Check Box9: Off

Date10_af_date:

Text11:

Date14_af_date:

Date15_af_date:

Date13_af_date:

Text16:

Date18_af_date:

Date19_af_date:

Date20_af_date:

Date21_af_date:

Text23:

Check Box24: Off

Check Box25: Off

Check Box26: Off

Check Box27: Off

Text30:

Date22_af_date:

Date17_af_date:

Date23_af_date:

Date24_af_date:

Check Box31: Off

Check Box32: Off

Date33_af_date:

Date34_af_date:

Date35_af_date:

Date36_af_date:

Date38_af_date:

Date39_af_date:

Text40:

CLEAR:

MF 5009

(Revised 02/01)

DEPARTMENT OF THE TREASURY

United States Mint Save As Print Form E-Mail Form Next Page

REQUEST FOR PRE-APPOINTMENT INVESTIGATION

TO: Chief, U.S. Mint Police FROM:

NAME: SSN:

DOB: POB: POSITION/GRADE

SENSITIVITY: SENSITIVE

NON-SENSITIVE

STATUS: FEDERAL

CONTRACTOR OTHER

EMPLOYEE REFERENCE (Report more than 2 if total work time is less than 5 years)

CURRENT EMPLOYER: MONTHS/YEARS THERE:

REFERENCE INFORMATION:

FORMER EMPLOYER: MONTHS/YEARS THERE:

REFERENCE INFORMATION:

FORMER EMPLOYER: MONTHS/YEARS THERE:

REFERENCE:

RESIDENCE (Report more than two if both are less than 5 years)

CURRENT ADDRESS: MONTHS/YEARS THERE:

CITY & STATE:

FORMER ADDRESS: MONTHS/YEARS THERE:

CITY & STATE:

PREVIOUS SECURITY INVESTIGATION INFORMATION

Investigating Agency:

Type of Investigation:

Date:

Clearance Level:

SF 75 Attached:

REQUESTING OFFICE INFORMATION

Date:

Name and Title:

Phone No.: Signature:

FOR SECURITY USE ONLY

DATE RECEIVED:

APPROVED:

DATE

RESULTS:

SUBMIT PERTINENT DOCUMENTS FOR NACI:

CHIEF, U.S. MINT POLICE

MF 5009

(Revised 02/01)

DEPARTMENT OF THE TREASURY

United States Mint Save As Print Form E-Mail Form Prev Page

BACKGROUND INFORMATION

For all questions, provide all additional requested information under item 6 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 1, 2, and 3, 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 you 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 whose record was expunged under Federal or State law.

1 During the last 10 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 6 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

2 Have you been convicted by a military court-martial in the past 10 years? (If no military service, answer

"(NO".) If "Yes", use item 6 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved

3 Are you now under charges for any violation of law? If "Yes", use item 6 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

4 During the last 5 years, were you 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? If "Yes", use item 6 to provide the date, an explanation of the problem and reason for leaving, and the employer's name and address.

5 Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefit, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and mortgage loans.) If "Yes", use item 6 to provide the type, length, and amount of the delinquently or default, and steps that you are taking to correct the error or repay the debt.

CONTINUATION SPACE / AGENCY OPTIONAL QUESTIONS

6 Provide details requested in items 1 though 5 and in the continuation 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).

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 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 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 lease at a later date.

Applicant's Signature (Sign in ink)

Date

Yes No

Attachment 1

Department of the Treasury Fair Credit Reporting Act

Disclosure and Authorization Form

This is a release for the Department of the Treasury to obtain one or more consumer/credit reports about you for an investigation in connection with your application for employment or in the course of your employment with the ________________/ Department of the Treasury, including your employment as a contractor. One or more reports about you may be obtained for employment purposes, including evaluating your suitability for employment, promotion or reassignment which results in a change to your position risk level, or access to classified information.

I, _____________________________, hereby authorize the Department of the Treasury to obtain such report(s) from any consumer/credit reporting agency for employment purposes. This authorization is valid for 5 years from the signed date, or upon the termination of my employment with ____________________/ Department of the Treasury, or until the investigation has been completed, whichever is sooner. If I apply for another position that requires a credit inquiry, I understand that I will be required to complete a new authorization.

Copies of this authorization that show my signature are as valid as the original signed by me.

Signature

Date

This form is in compliance with the Privacy Act of 1974. Our authorized right to ask for this information is 5 U.S.C. 301 and Executive Order 10450, which established the criteria for sensitive Government positions. The information you supply by signing this release of information form will be used principally to aid in the completion of an investigation to determine your suitability for employment in the Federal service or for other employment purposes. Such purposes include, but are not limited to, a security clearance, evaluation of qualification, suitability, loyalty to the United States, eligibility for access to government information, facilities, or information technology systems, or congressional inquiries. The information obtained may be re-disclosed to other Federal agencies for the above purposes and to the extent that is authorized by law.

Your signature on this release is voluntary, however, your failure to complete this form may mean that the required information cannot be obtained to complete your investigation. This may affect your placement or security clearance prospects.

If the Department of the Treasury intends to take any adverse action based in whole or in part on your credit report, you are entitled to certain protections set out in the Fair Credit Reporting Act, 15 U.S.C. 1681b. These protections are shown on the reverse side of the form.

TD F 15-03.9

including your employment as a contractor One or more reports about you may be obtained for: U.S. Mint obtain such reports from any consumercredit reporting agency for employment purposes This:

investigation has been completed whichever is sooner If I apply for another position that: U.S. Mint

Date:

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 2019

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. Were you born a male 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 your only active duty was training in the Reserves or National Guard, answer "NO.”

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

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 charges, 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.

YES NO

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 received a tentative/conditional job offer or have not yet been selected, carefully review your answers on this form and any attached sheets.

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:

(MM / DD / YYYY)

17b. Appointee's Signature: Date:

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:

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.

YES NO DO NOT KNOW

YES NO DO NOT KNOW

Appointing Officer:

Enter Date of Appointment or Conversion

MM / DD / YYYY

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

Instructions

Privacy Act Statement

Public Burden Statement

General Information

Selective Service Registration

Military Service

Background Information

Additional Questions

Continuation Space / Agency Optional Questions

Certifications / Additional Questions

Name:

SSN:

PlaceBirth:

Citizen: Off

CitizenCountry:

Birthdate:

OtherNames:

DayPhone:

NightPhone:

Male: Off

SelectiveService: Off

Military: Off

Branch1:

From1:

To1:

Discharge1:

Branch2:

Branch3:

From2:

From3:

To2:

To3:

Discharge2:

Discharge3:

Convixted: Off

Court-Martial: Off

CurrentCharges: Off

Fired: Off

Debt: Off

Relatives: Off

Retirement: Off

Explanation:

LeaveLastJob:

CancelWaiver: Off

BasicLifeInsurance: Off

ApplicantDate:

AppointingOfficerDate:

AppointeeDate:

Security Packet

Non-disclosure Agreement for Contract Employees Conditional Access to Sensitive but Unclassified Information

Sample

CONTRACT NUMBER:

I, , hereby consent to the terms in this Agreement in consideration of my being granted conditional access to certain United States Government documents or material containing sensitive but unclassified information.

I understand and agree to the following terms and conditions:

1. By being granted conditional access to sensitive but unclassified information, 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.

2. As used in this Agreement, sensitive but unclassified information is any information, the loss, misuse, or unauthorized access to or modification of which could adversely affect the national interest or the conduct of Federal programs, or the privacy to which individuals are entitled under Title 5 U.S.C. § 552a, 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.

3. I am being granted conditional access upon my execution of this Agreement for the sole purpose of (identify the nature of contract work or special project). This approval will permit me conditional access to certain information, (identify type(s) of information, e.g., documents, memoranda, reports, testimony, deliberations, maps, drawings, schematics, plans, assessments, etc. ) and/ or to attend meetings in which such information is discussed or otherwise made available to me. This Agreement will not allow me access to materials which the United States Mint has predetermined, at its sole discretion, are inappropriate for disclosure pursuant to this Agreement. This may include sensitive but unclass-ified information provided to the United States Mint by other agencies of the US Government.

4. I will never divulge any sensitive but unclassified information which is provided to me pursuant to this Agreement to anyone, unless I have been advised in writing by the United States Mint that the individual is authorized to receive it. Should I desire to make use of any sensitive but unclassified information, I will do so in accordance with paragraph 6 of this Agreement. I will submit to the United States Mint for security review, prior to any submission for publication, any book, article, column or other written work for general publication that is based upon any knowledge I obtained during the course of my work on this contract in order for the United States Mint to ensure that no sensitive but unclassified information is disclosed.

5. I hereby assign to the United States Government all royalties, remuneration, and emoluments that have resulted, will result or may result from any disclosure, publication, or revelation of sensitive but unclassified information not consistent with the terms of this Agreement.

6. If I am permitted, at the sole discretion of the United States Mint, to review any official documents containing sensitive but unclassified information, such review will be conducted at a secure facility or under circumstances which will maintain the security protection of such material. I will not be permitted to and will not make any copies of documents or parts of documents to which conditional access is granted to me. Any notes taken during the course of such access will remain at the United States Mint to be placed in secure storage unless it is determined by United States Mint officials that the notes contain no sensitive but unclassified information. If I wish to have the notes released to me, United States Mint officials will review the notes for the purposes of deleting any sensitive but unclassified information to create a redacted copy of the notes. If I do not wish a review of any notes that I make, those notes will remain sealed in secure storage at the United States Mint.

Security Packet

7. If I violate the terms and conditions of this Agreement, I understand that the unauthorized disclosure of sensitive but unclassified information could compromise the security of the United States Mint.

8. If I violate the terms and conditions of this Agreement, such violation may result in the cancellation of my conditional access to sensitive but unclassified information. This may serve as a basis for denying me conditional access to United States Mint information, both classified and sensitive but unclassified in the future. If I violate the terms and conditions of this Agreement, the United States may institute a civil action for damages or any other appropriate relief. The willful disclosure of information to which I have agreed therein not to divulge may constitute a criminal offence.

9. Unless and until I am provided a written release by the United States Mint from this Agreement or any portions of it, all conditions and obligations contained in this Agreement apply both during my period of conditional access, which shall terminate at the conclusion of my work on this contract, and at all times thereafter.

10. 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.

11. I understand that the United States Government 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.

12. By granting me conditional access to information in this context, the United States Government does not waive any statutory or common law evidentiary privileges or protections that it may assert in any administrative or court proceeding to protect any sensitive but unclassified information to which I have been given conditional access under the terms of this Agreement.

13. These restrictions are consistent with and do not supersede, conflict with or otherwise alter the employee obligations, rights or liabilities created by Executive Order 12356; 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 U.S.C. 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, 798, and 952 of Title 18, United States Code, and Section 4(b) of the Subversive Activities Act of 1950 (50 U.S.C. Section 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.

14. My execution of this Agreement shall not nullify or effect in any manner any other secrecy or nondisclosure Agreement which I have executed or may execute with the United States Government.

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

Name Date

This Agreement was accepted by the undersigned on behalf of the United States Mint as a prior condition of conditional access to sensitive but unclassified information.

United States Mint Contracting Officer or COR Date

Non-disclosure Agreement for Contract Employees

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