State of PA recompete____Exhibit 2.pdf

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Francis, Inigo F 9.0.0.2.20120627.2.874785 Federal Protective Service National Protection and Programs Directorate U.S. Department of Homeland Security Exhibit 2 Contractor Information Worksheet CIWRC V2. April 2014 Type Contractor

PSO

Non-PSO

1. Contract Employee/Applicant Information NAME: Las t First Middle Suffix Social Security Date of Birth

MMDDYYY

Y Place of Birth: City State Country Personal E mail Address Phone # (Day) Phone # (Cell) Position (Job) Title Sex Male Female U.S. Born Yes No Port of Entry Date of Entry Naturalization # (if applicable)

2. Contract Information Company Name Company is Prime Sub Contractor If Sub, Name of Prime Contract /Work Order / RWA # Contract Start Date End Date Has Option Years

OR

End Date TBD Company Point of Contact (POC) Name Phone # (Day) E mail Address of Co POC

3. Project/Work Location Information (Government site where contractor is working) Building Name GSA Building # Building Address

4. Type of Investigation Requested for HSPD 12 PIV Card Credential and Fitness Adjudication Public Trust Positions (Required – Select risk level) Moderate Risk - (MBI) High Risk - (BI) National Industrial Security Clearance (Optional – select clearance level) Secret (NACLC) Top Secret (SSBI)

5. Requesting Official (Sponsor) Information Sponsor's Name Title FPS Regional Office Number E mail Address Phone # (Day) Review Date

6. Regional Contract Adjudication Unit Staff use only

INTAKE

e-QIP Invitation # Forms Received:

FD 258 (2)

RELease CERtification Med Release

OF-306

DHS 11000-9

Credit Release

RECIPROCITY

CVS

Investigation Type:

Inv #:

Status:

Copy ROI Ordered? Yes No

AUTOMATED RECORD CHECKS

NCIC (Open Fox) CIS Naturalized Equifax

FD 258

RAP

Date Forms Received SF85P-SReviewed Reciprocity or Scanned/TIF Date Sent to OPM Fitness Decision Preliminary Date Favorable Unfavorable Final Date Favorable Unfavorable Notify Preliminary Decision email: COR/ Requesting Official email: Subject email: Subject’s Company POC Final Decision email: COR/ Requesting Official email: Subject email: Subject’s Company POC Date email sent Fitness Date:

Comments/Notes:

FPS Contractor Information Worksheet Privacy Statement

Authority: 5 U.S.C. § 301; 44 U.S.C. § 3101; Homeland Security Act of 2002, Pub. L. No. 107-296, 116 Stat. 2135; Executive Order (EO) 9397; EO 10450; EO 12968; and 5 CFR Part 731 authorize the collection of this information.

Purpose: The primary purpose of this collection is to facilitate the screening of an individual for a contractor position to perform services for the Federal government.

Routine Uses: The information collected may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using the information as necessary and authorized by the routine uses published in DHS/ALL-023 - Department of Homeland Security Personnel Security Management, 75 FR 8088 (February 23, 2010).

Disclosure: Participation is voluntary; however, failure to provide this information may delay the individual from being able to perform services for the Federal government.

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