Attachment G - PSIP Request.pdf

Personnel Security Investigation Request

Privacy Act Statement Authority: 10 U.S.C. 3013, 50 U.S.C. 4039, and the National Security Act of 1947; E.O 10450 and 10865; and E.O. 9397 (SSN).

Principle Purpose(s): To obtain or retain a security clearance.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:

Information may be released to federal agencies based on formal accreditation as specified in official directive, regulations, and demonstrated need-to-know; to federal, state, local, and foreign law enforcement, intelligence, or security agencies in connection with a lawful investigation under their jurisdiction; and to commanders/agency heads for adverse personnel actions.

The DoD 'Blanket Routine Uses' set forth at the beginning of the Army's compilation of systems of records notices also apply to this system.

Disclosure: Disclosure of SSN is voluntary; however, failure to provide SSN may result in access being denied.

APPLICANT INFORMATION

SSN: □ MILITARY □ CIVILIAN □ CONT RACT OR

GRADE:

LAST NAME: FIRST: MIDDLE:

SUFFIX (Sr.,Jr.,I, II, etc.): DATE OF BIRTH (MM/DD/YYYY):

COUNTRY OF BIRTH: STATE OF BIRTH: CITY OF BIRTH:

U.S. CITIZEN: YES □ NO □

VERIFICATION :

DOCUMENT NUMBER:

PCS DATE: ETS DATE: RETIREMENT DATE:

UNIT/ORGANIZATION/COMPANY:

PRIMARY E-MAIL (OFFICIAL (.MIL) RECOMMENDED):

ALTERNATE E-MAIL:

PRIMARY PHONE#: ALTERNATE PHONE#:

ACTION REQUESTED

INVESTIGATION REQUIRED:

PERIODIC REINVESTIGATION:

YES □ NO □

INTERIM REQUIRED:

YES □ NO □

FINGERPRINT INFORMATION

FINGERPRINT APPOINTMENT (ONLY REQUIRED FOR INITIAL CLEARANCES):

WITH: DATE: TIME:_______________________________

JUSTIFICATION/REASON FOR INVESTIGATION

□ MOS CODE (MILITARY ONLY) (e.g., 96B):

□ POSITION DESCRIPTION/DD2875(ATTACHED)

□ OTHER (PROVIDE SPECIFIC DETAILS OF THE REQUIREMENT):

SUPERVISOR INFORMATION

SUPERVISOR RANK: FIRST NAME: LAST NAME:

TITLE: EMAIL ADDRESS:

PHONE: REMARKS:

I certify that this individual requires the background investigation for valid employment offer or mission requirements.

SIGNATURE:

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