Attachment_3-_Request_for_Personnel_Security_Action_(AF_2583).pdf

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REQUEST FOR PERSONNEL SECURITY ACTION

AUTHORITY: 10 U.S.C. 8012; 44 U.S.C. 3101; and EO 9397.

PRINCIPAL PURPOSES: To identify investigation, security clearance, unescorted entry requirements, and special access program authorizations.

ROUTINE USES: To request personnel security investigations, record emergency or limited access authorization, entry to restricted areas, and to record special access program authorizations. SSN is used for positive identification of the individual and records.

DISCLOSURE IS VOLUNTARY: Failure to information and SSN could result in assignment to less sensitive duties.

IDENTIFYING INFORMATION

I.

2. ORGANIZATION OR FIRM SPONSOR

1. NAME (Last, First, Middle, Maiden)

3. GRADE

4. SSN

5.

CITIZENSHIP

US CITIZEN

IMMIGRANT ALIEN

NON-US NATIONAL

7. PLACE OF BIRTH

6. DATE OF BIRTH

(City, State, and Country)

II.

INVESTIGATION, CLEARANCE, ELIGIBILITY, ENTRY AND ACCESS REQUIREMENTS

8.

INVESTIGATION REQUIREMENT

9.

CLEARANCE, ENTRY OR ACCESS REQUIREMENT

ONE-TIME ACCESS

LIMITED ACCESS

INTERIM CLEARANCE

SPECIAL ACCESS

National Agency Check and Inquiries (NACI) National Agency Check with Law and Credit (NACLC) or Access

UNESCORTED ENTRY

National Agency Check and Inquiries.

Single Scope Background Investigation (SSBI)

TOP SECRET

Priority Level 1 Secret Periodic Reinvestigation

SECRET

Priority Level 2 SSBI or PPR Periodic Reinvestigation Priority Level 3 Priority Level 4

III.

LOCAL FILES CHECK

10. TO:

11. FROM:

12. DATE

13. TYPED NAME, GRADE AND TITLE OF REQUESTER

14. SIGNATURE

IV.

MEDICAL RECORDS CHECK

15. I CERTIFY a medical records check required by AFI 31-501 or its replacement has been completed and no information exists, unless shown in Section VII, which would preclude the granting of eligibility of security clearance, access to special programs or unescorted entry to restricted areas.

17. TYPED NAME AND GRADE OF BASE DIRECTOR, MEDICAL SERVICES

16. DATE

18. SIGNATURE

V.

SECURITY POLICE RECORDS CHECK

19.

I CERTIFY a security police records check required by AFR 205-32, has been completed and no information exists, unless shown in Section VII, which would preclude the granting of a security clearance, unescorted entry to restricted areas, or access to special program classified information.

20. DATE

21. TYPED NAME AND GRADE OF SECURITY POLICE OFFICIAL

22. SIGNATURE

VI.

ACCESS AUTHORIZATION

ONE-TIME ACCESS

LIMITED ACCESS

CNWDI

NATO

RD

NC2-ESI

CONTINUING

ONE-TIME

23. I CERTIFY the named individual requires access to the above special program(s), meets all investigative and clearance requirements, and has been briefed on program responsibilities as outlined in the governing directive. If applicable, emergency or limited access is necessary and will not endanger the national security.

24. DATE

25. TYPED NAME, GRADE AND TITLE OF APPROVING AUTHORITY

26. SIGNATURE

28. TYPED NAME, GRADE AND TITLE OF SPECIAL ACCESS PROGRAM

CERTIFYING OFFICIAL

27. DATE

29. SIGNATURE

VII.

REMARKS

(If more space is needed, use reverse and show item number being continued)

AF 2583, 20140404, V3

PREVIOUS EDITION WILL BE USED.

Click to sign Click to sign Click to sign Click to sign Click to sign PRIVACY ACT INFORMATION: The Information in this form is FOR OFFICAL USE ONLY. Protect lAW the Privacy Act of 1974.

8.2.1.3158.1.475346.466429