Blank 4311 Form_C.pdf
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- Solicitation number
- ODNI-FMS-25-01
About this file
This is a Form 4311 Industrial Security Approval or Access Request form, which appears to be an initial request for security clearance. The form is partially completed, with the Contracting Officer's Technical Representative (COTR) identified as Diana Jeffries, with a contact number of 703-275-3092. The security access level requested is ISSA/TS (Interim Secret Special Access/Top Secret), and the form includes a checkbox for adding a no-escort badge. The document is dated February 2020 and is designed for government use in processing personnel security clearances, with sections for various types of security actions, clearance levels, and approval tracking. Most of the form's specific details about the individual requesting clearance are left blank in this version.
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Text version
FORM 4311 / INDUSTRIAL SECURITY APPROVAL OR ACCESS REQUEST
C O
N T
R A
C T
O R
DATE OF REQUEST (YYMMDD): SUBJECT NAME (LAST, FIRST MI):
SSN: SFN: POB (CITY, STATE/COUNTRY):
DOB (YYMMDD): PHYSICAL ADDRESS:
PRIME CONTRACTOR NAME: SUB-CONTRACTOR NAME (IF APPLICABLE):
RETURN MAILING ADDRESS:
(NAME)
(STREET ADDRESS OR PO BOX)
(CITY, STATE AND ZIP CODE) FAX:
CONTRACT SECURITY OFFICER (NAME AND SIGNATURE): PHONE:
ALT. CONTRACT SEC. OFFICER (NAME AND SIGNATURE): PHONE:
TYPE OF ACTION:
☐ INITIAL ☐ REINVESTIGATION
☐ CROSSOVER ☐ CANCELLATION
☐ BADGE RENEWAL ☐ TERMINATION
☐ CONTRACT CHANGE ☐ UN-TERMINATION
☐ OTHER (INCLUDE DESCRIPTION IN COMMENTS SECTION)
LEVEL OF ACCESS:
☐ FACILITY ACCESS AUTHORIZATION LIMITED (FAA/L)
☐ ISA/S ☐ ISA/TS ☒ ISSA/TS
☐ ADD SCI *LIST SCI ACCESS REQUESTED* SELECT ONE
☒ ADD NO-ESCORT BADGE (FOR ISSA/TS ONLY)
VENDOR CODE: CONTRACT NUMBER:
ASSOCIATION: SC-0 ☒ SC-1 ☐
SPONSORING COMPONENT
(DIRECTORATE OFFICE, ETC):
PERIOD OF PERFORMANCE: SLA/BUDGET CODE:
CDCG PERSONNEL CLEARANCE LEVEL: ISA/S ☐ ISA/TS ☐ ISSA/TS ☒
NEW CLEARANCES REQUIRED: NEW CLEARANCES REQUIRED SUBMITTED TO DATE:
DOES SUBJECT HAVE A CLEARANCE HISTORY? ☐ YES ☐ NO ☐ UNKNOWN
IF YES: GRANTING AGENCY: CLEARANCE LEVEL:
DATE GRANTED (YYMMDD): DATE DEBRIEFED (YYMMDD):
COMMENTS:
C O
T R
**By signing this form, I agree that the requirement for this person to be cleared against the above referenced contract is valid**
COTR NAME (PRINTED): Diana Jeffries PHONE NUMBER: 703-275-3092
COTR SIGNATURE: CONCURRENCE DATE (YYMMDD):
A P
P R
O V
A L
US GOVERNMENT USE ONLY
☐ APPROVED APPROVAL DATE (YYMMDD): _________________ SFN: _______________
BI DATE (YYMMDD): _________________________
POLY DATE (YYMMDD): ______________________ APPROVING AUTHORITY
FORM 4311 FEB 2020 PREVIOUS EDITIONS OBSOLETE SCI’S MUST BE BRIEFED WITHIN SIX MONTHS OF
APPROVAL DATE AND CANNOT PRECEDE APPROVAL
SELECT ONE
SELECT ONE
Select One
SELECT ONE
File details come from the government source that posted it. Updated .