Attachment 9 - Contractor CAC Request Form.pdf

U.S. Army Corps of Engineers, Huntsville Engineering and Support Center Request for Common Access Card (CAC) May 2020

This page become FOR OFFICIAL USE ONLY when filled in. Page 1

Contractor Information Government Information

Company Name: New Request: Renewal:

Security Manager (SM): POC/PM/PgM/COR/KO:

SM Email: Telephone No:

Contract Number: TRUSTED AGENT:

Contract Exp. Date: Telephone No:

***The Contractor listed below requires a NACI or NACLC (w/o a Clearance) to be issued a CAC.

You are required to circle one or the other before submitting to the Security Office.

Full Legal Name: Date of Birth:

SSN: Place of Birth:

Email: 10 Digit Telephone No:

Type/Date of Investigation: Job Title

Level of Access Required: U.S. Citizen:

Clearance/Date Granted: Verification Provided? Yes No

Granted by: Foreign National/List Country:

1. Project Manager/Program Manager/Contract Officer Representative/Contracting Officer or their designated Point-of- Contact (PM/PgM/COR/KO/POC) certify that the above named contractor meets the requirements of DoDM 1000.13-M-V1, January 23, 2014, Enclosure 2, Paragraph 1.b.(1) through

1.b.(3) which states that the contractor requires (1) Both access to a DoD facility and access, via logon, to DoD networks onsite or remotely, (2) Remote access via logon, to a DoD network using

DoD-approved remote access procedures, (3) Physical access to multiple DoD facilities or multiple non-DoD federally controlled facilities on behalf of the DoD on a recurring basis for a period of 6 months or more.

- The primary HNC POC is responsible for providing the completed form to the HNC Security Office at least 10 working days prior to the entrance on duty date of the Contractor employee.

2. The Contractor’s Security Manager (CSM) certifies they have verified the above individual’s security status in JPAS to ensure they meet the security requirements IAW HSPD-12.

- If the individual does meet the security requirements the only submission required is this form.

- I f the individual does not meet the security requirements the CSM will submit a package consisting of:

- Fully completed and signed CAC Request Form - *By signing this form the CSM acknowledges only legible forms and complete packages will be accepted.

- 2 Fingerprint cards (Only acceptable on the FD-258 form unless done electronically).

- Copy of current U.S. Passport or Birth Certificate and Driver’s License

- Signed letter of verification from the contractor’s security office that the current

U.S. Passport or Birth Certificate/Driver’s License was verified by their office.

- Completed OF306 Declaration of Federal Employment.

- **Foreign Nationals – CSM must send a signed memorandum verifying that the applicant has no criminal records/warrants in their country of record.

Cont’d on page 2

U.S. Army Corps of Engineers, Huntsville Engineering and Support Center Request for Common Access Card (CAC) May 2020

This page become FOR OFFICIAL USE ONLY when filled in. Page 2

**If a package is not received complete, the HNC Security Office will send a maximum of 2 notifications

(emails) to the Contractor’s security office within a 2 week period. If no response is received the incomplete package will be destroyed and the process will have to be started from the beginning.

3. Once the HNC Security Office receives the completed package (above) from the HNC

PM/PgM/COR/KO/POC the HNC Security Office will submit a Personnel Security Investigation Portal

(PSIP) request for the applicant. The applicant will receive a notification email from PSIP stating what will be needed to complete the form. The second email the applicant will receive will be the form that needs to be completed. Once received, the PSIP form must be completed in 5 calendar days.

4. CSM also acknowledges that contract employees who fail to respond within the given PSIP time constraints will be terminated.

- When the PSIP process is terminated a written justification – including corrective actions taken - must be provided to the POC/PM/PgM/COR/KO from the CSM.

- To reinitiate the process the POC/PM/PgM/COR/KO must sign the justification indicating their approval before providing a copy to HNC’s Security Office and the Trusted Agent (TA).

5. The Contractor Security Manager will ensure that the CAC is returned to the POC/PM/PgM/COR/KO, who in turn will forward the CAC to the Security Office when the contract employee separates or is terminated and/or is no longer eligible for a CAC IAW above requirements.

* * When a CAC is lost or stolen the Contractor Security Manager will provide written notification detailing the incident to the POC/PM/PgM/COR/KO. The POC/PM/PgM/COR/KO will sign the notification and forward to the Security Office.

** NOTE: In and out processing appointments can be made with the Security Office by calling Ms. Cobb at 256-895-1592 or Ms. Cook at 256-895-1497. The Contractor MUST be vetted before being allowed to in-process.

Printed Name of Contractor Security Manager: Date:

Signature:

Printed Name of POC/PM/PgM/COR/KO: Date:

Signature: