Attachment_3-NOAA_Security_Form.pdf

Name (First Middle Last)

Other Names Used

SSN

Gender

Email Address

Country of Citizenship Dual Citizenship

Visa Number Alien Registration Number

Date of Birth

Place of Birth (City, State, and Country)

Position Title Position Sensitivity

Nature of Action (If Employee)

Geographic Code (If Employee)

Bureau / Line Office

Organization Code

Duty Station Contract Company

Contract Number

Start Date (EOD)

End Date

Accounting Code Supervisor & Supervisor Phone #

Previous DOC Assignments

Previous Federal / DOC Work Dates

Badge Required *(See Note 2)

Date:

HR/COR/Sponsor:

Phone Number:

Email Address:

U.S. Department of Commerce / Office of Security

Volunteer/Student Contractor

Foreign National *(See Note 1)

Employee

Associate/Guest

SUBJECT: Security Coversheet / Request for Investigation Coversheet

* NOTES:

1)

You must complete additional requirements listed in DAO 207-12 to obtain authorization for foreign national access to a DOC facility. Please contact your Servicing Security Office if you have any questions.

2)

If a person is with DOC for:

<30 days: Fingerprint check is required; a non-HSPD-12 ID will be issued with applicable expiration date.

>30 days and <180 days: Fingerprint check is required and an OFI-86C (ACDH) is required; a non-HSPD-12 ID will be be issued with applicable expiration date >180 days: Requires the appropriate background investigation. An approved HSPD-12 will be issued.

Revised 05/22/2009

Name (First Middle Last) Other Names Used

SSN

Gender Email Address Country of Citizenship Dual Citizenship Visa Number Alien Registration Number Date of Birth Place of Birth (City, State, and Country) Position Title Position Sensitivity Nature of Action (If Employee) Geographic Code (If Employee) Bureau / Line Office Organization Code Duty Station Contract Company Contract Number Start Date (EOD) End Date Accounting Code Supervisor & Supervisor Phone # Previous DOC Assignments Previous Federal / DOC Work Dates Badge Required *(See Note 2) Date:

HR/COR/Sponsor:

Phone Number:

Email Address:

U.S. Department of Commerce / Office of Security C:\Documents and Settings\jhaack\My Documents\My Pictures\dev01_002608.gif SUBJECT: Security Coversheet / Request for Investigation Coversheet

* NOTES:

1)

You must complete additional requirements listed in DAO 207-12 to obtain authorization for foreign national access to a DOC facility. Please contact your Servicing Security Office if you have any questions.

2)

If a person is with DOC for:

<30 days: Fingerprint check is required; a non-HSPD-12 ID will be issued with applicable expiration date.

>30 days and <180 days: Fingerprint check is required and an OFI-86C (ACDH) is required; a non-HSPD-12 ID will be be issued with applicable expiration date >180 days: Requires the appropriate background investigation. An approved HSPD-12 will be issued.

Revised 05/22/2009 8.0.1291.1.339988.308172

(206) 526-6006 jhaack@doc.gov

DOC/OSY/CSSD/WRSO

Jason Haack Security Coversheet