Exhibit_14_DHS_11000-14_PACS_User_Agreement.pdf
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- HSHQEC-16-R-00004
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DEPARTMENT OF HOMELAND SECURITY
PACS USER AGREEMENT
FIRST NAMELAST NAME MIDDLE NAME
SECTION I - PERSONAL INFORMATION (Completed by Individual)
SOCIAL SECURITY NUMBER DATE OF BIRTH SEX EMAIL ADDRESS
HOME ADDRESS ADDRESS 2
CITY
SECTION II - EMPLOYEE INFORMATION (Completed by Employee) TYPE OF EMPLOYEE (Check One)
DIRECTORATE/OFFICE HOME AGENCY (Detailee) COMPANY (Contractor)
DHS Form 11000-14 (6/13) Page 1 of 1
STATE ZIP HOME PHONE
SECTION III - ACCESS CONTROL OFFICE / SIGNATURE AUTHORITY - SSO
USER AGREEMENT
SECURITY CLEARANCE LEVEL
BADGE TYPE BADGE NUMBER
ISSUE DATE
PRINTED NAME - DHS SIGNATORY AUTHORITY (TS-BELOW)
EXPIRATION DATE STATUS
SIGNATURE
LOCATION (Check One)
AUTHORITY: 5 U.S.C. 5701-5733, §§ 5721-5733 and Executive Order 9397.
PRINCIPAL PURPOSE(S): This information is being collected for the sole purpose of identifying that all requirements have been met to apply for and receive DHS HQ PACS Access.
ROUTINE USE(S): "The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/ALL - 014 Emergency Personnel Location Records System of Records (73 FR 61888, October 17, 2008)."
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested will prevent the individual from receiving any access level assignment to HQ PACS.
PRIVACY ACT STATEMENT
PRINTED NAME - SSO (TS/SCI ONLY)
• I ACKNOWLEDGE THE PIV CARD IS ACCOUNTABLE GOVERNMENT PROPERTY. IT MUST BE RETURNED TO THE ACCESS CONTROL
OFFICE WHICH ISSUED IT AT THE END OF YOUR ASSOCIATION WITH DHS.
• THE PIV CARD MUST BE WORN IN PLAIN SIGHT BETWEEN THE SHOULDERS AND THE WAIST AT ALL TIMES WHILE ON A DHS FACILITY.
• IT MUST BE HIDDEN FROM SIGHT WHENEVER OUTSIDE A GOVERNMENT FACILITY.
• YOU WILL BE REQUIRED TO REMEMBER THE PIN NUMBER YOU SELECT TO UTILIZE THE PHYSICAL AND LOGICAL ACCESS
FUNCTIONALITY OF THE CARD.
• IT IS YOUR RESPONSIBILITY TO REMOVE YOUR CARD FROM YOUR COMPUTER WHEN YOU LEAVE IT UNATTENDED.
• YOU ARE RESPONSIBLE FOR KNOWING THE EXPIRATION DATE OF YOUR PIV CARD.
FEDERAL EMPLOYEE FEDERAL DETAILEE CONTRACTOR OTHER
NONE SECRET OTHERTOP SECRET
OTHERVERMONT AVENUE7TH & DNEBRASKA AVENUE
DATE
SIGNATURE DATE
EMPLOYEE SIGNATURE DATE
DHS- 11000- 14
PAM WASHINGTON
IDENTIFICATION ACCESS CONTROL CARD REQUEST DOCUMENT
D:20050825183926- 04'00' D:20050825183926- 04'00'
DEPARTMENT OF HOMELAND SECURITY
PACS USER AGREEMENT
FIRST NAME
LAST NAME
MIDDLE NAME
SECTION I - PERSONAL INFORMATION (Completed by Individual) SECTION 1 - PERSONAL INFORMATION (Completed by Individual)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
SEX
EMAIL ADDRESS
HOME ADDRESS
ADDRESS 2
CITY
SECTION II - EMPLOYEE INFORMATION (Completed by Employee) SECTION 2 - EMPLOYEE INFORMATION (Completed by Directorate Authorized Representative) TYPE OF EMPLOYEE (Check One)
DIRECTORATE/OFFICE
HOME AGENCY (Detailee) COMPANY (Contractor) DHS Form 11000-14 (6/13) D H S Form 1 1 0 0 0 - 14 (12/03) D H S Form 1 1 0 0 0 - 14 (12/03)
STATE
ZIP
HOME PHONE
SECTION III - ACCESS CONTROL OFFICE / SIGNATURE AUTHORITY - SSO
SECTION 3 - SECURITY INFORMATION (Completed by Security Office)
USER AGREEMENT
SECTION 3 - SECURITY INFORMATION (Completed by Security Office)
SECURITY CLEARANCE LEVEL
BADGE TYPE
BADGE NUMBER
ISSUE DATE
PRINTED NAME - DHS SIGNATORY AUTHORITY (TS-BELOW)
EXPIRATION DATE
STATUS
SIGNATURE
LOCATION (Check One) AUTHORITY: 5 U.S.C. 5701-5733, §§ 5721-5733 and Executive Order 9397.
PRINCIPAL PURPOSE(S): This information is being collected for the sole purpose of identifying that all requirements have been met to apply for and receive DHS HQ PACS Access.
ROUTINE USE(S): "The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/ALL - 014 Emergency Personnel Location Records System of Records (73 FR 61888, October 17, 2008)."
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested will prevent the individual from receiving any access level assignment to HQ PACS.
PRIVACY ACT STATEMENT
PRINTED NAME - SSO (TS/SCI ONLY)
• I ACKNOWLEDGE THE PIV CARD IS ACCOUNTABLE GOVERNMENT PROPERTY. IT MUST BE RETURNED TO THE ACCESS CONTROL OFFICE WHICH ISSUED IT AT THE END OF YOUR ASSOCIATION WITH DHS.
• THE PIV CARD MUST BE WORN IN PLAIN SIGHT BETWEEN THE SHOULDERS AND THE WAIST AT ALL TIMES WHILE ON A DHS FACILITY.
• IT MUST BE HIDDEN FROM SIGHT WHENEVER OUTSIDE A GOVERNMENT FACILITY.
• YOU WILL BE REQUIRED TO REMEMBER THE PIN NUMBER YOU SELECT TO UTILIZE THE PHYSICAL AND LOGICAL ACCESS FUNCTIONALITY OF THE CARD.
• IT IS YOUR RESPONSIBILITY TO REMOVE YOUR CARD FROM YOUR COMPUTER WHEN YOU LEAVE IT UNATTENDED.
• YOU ARE RESPONSIBLE FOR KNOWING THE EXPIRATION DATE OF YOUR PIV CARD.
DATE
SIGNATURE
DATE
EMPLOYEE SIGNATURE
DATE
| FIRST NAME: |
| EMAIL ADDRESS: |
| CITY: |
| STATE: |
| ZIP: |
| SEX: |
| MIDDLE NAME: |
| LAST NAME: |
| HOME ADDRESS: |
| ADDRESS 2: |
| SPECIFY OTHER: |
| DIRECTORATE/OFFICE: |
| HOME AGENCY (Detailee) : |
| COMPANY (Contractor) : |
| BADGE TYPE: |
| PRINTED NAME - SSO (TS/SCI ONLY): |
| BADGE NUMBER: |
| STATUS: |
| SIGNATURE. This is a protected field.: |
| OTHER: 0 |
| TOP SECRET: 0 |
| LOCATION (Check one). NEBRASKA AVENUE: 0 |
| SOCIAL SECURITY NUMBER. Enter 9 digit social security number.: |
| DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.: |
| ISSUE DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| EXPIRATION DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| DATE OF SIGNATURE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| SIGNATURE. This is a protected field.: |
| DATE OF SIGNATURE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| EMPLOYEE SIGNATURE. This is a protected field.: |
| DATE OF SIGNATURE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| HOME PHONE. Enter 10 digit telephone number including area code.: |
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