Attachment 8 -Background Investigation Clearance Form.pdf

BACKGROUND INVESTIGATION/CLEARANCE VERIFICATION

Executive Order 13467 – Reforming Process Related to Suitability for Government Employment, Fitness for Contractor Employees, and Eligibility for Access to Classified National Security Information, requires that Agencies verify prior background investigations and/or security clearances of employees, contractors and other individuals nominated for unescorted access to Federal Government facilities, in order to avoid duplicative investigative activity. Please provide the following information to assist in this verification process.

1. Has an Agency of the United States Government ever investigated your background?

Yes ____ No ____

Date of most recent investigation _____________________

Investigating agency _______________________________

Type investigation _________________________________

2. Has an Agency of the United States Government ever granted you a security clearance?

Yes ______ No _____

Granting agency ___________________________________

Level of clearance _________________________________

Date issued ______________________________________

3. To your knowledge, have you ever had a clearance or access authorization denied, suspended, or revoked, or have you been debarred from government employment? (Note: An administrative downgrade or an administrative termination of a security clearance is not a revocation.)

Yes _____ No _____

Initiating agency __________________________________

Date action taken _________________________________

Name (Printed) _____________________________________________

Signature__________________________________________________

SSN:__________________________ DOB:_____________________

Place of Birth ______________________________________________