ssf3237_-_Facility_Access_Request.pdf

DD-254 ON FILE?SCI (4C/4N)

LENGTH OF TIME YOU WORKED

FOR THIS EMPLOYER

9. TYPE OF APPLICANT

17. IF YOU ARE A U.S. CITIZEN OTHER THAN BY BIRTH, PROVIDE THE FOLLOWING: 16. DO YOU HOLD U.S. CITIZENSHIP STATUS?

8. SEX

DEPARTMENT OF HOMELAND SECURITY

United States Secret Service

U.S. SECRET SERVICE FACILITY ACCESS REQUEST

1. FULL NAME (last, first, middle) 2. MAIDEN NAME (if applicable)

4. SOCIAL SECURITY NUMBER3. OTHER ALIAS (last, first, middle)

7. DRIVERS LICENSE NO. AND STATE6. PLACE OF BIRTH (city, state, country)5. DATE OF BIRTH (month/day/year)

WEIGHT HAIR COLOR 9. RACEEYE COLORHEIGHT American Indian or Alaskan Native Hispanic or Latino

Female Asian Native Hawaiian or other Pacific Islander

Male Black or African American White

11. TELEPHONE (area code, number)10. PRESENT ADDRESS (street address, city, state, zip code) LENGTH OF TIME AT THIS ADDRESS Work:

Years Residence:

Months Cellular:

13. SPOUSE'S NAME AND ADDRESS (if applicable)12. MARITAL STATUS

15. NAME OF SUPERVISOR AND TELEPHONE NUMBER (with area code)14. NAME AND ADDRESS OF EMPLOYER (company/agency)

Years

Naturalization Certificate No.:

Date of Issuance:

Page 1 of 2SSF 3237 (Rev. 08/2013)

SECTION A - TO BE COMPLETED BY THE U.S. SECRET SERVICE RESPONSIBLE OFFICE

1. NAME OF USSS RESPONSIBLE OFFICE 2. USSS POINT OF CONTACT (Last, First, Middle) 3. TELEPHONE NUMBER (with area code)

SECTION B - TO BE COMPLETED BY APPLICANT

Months

PLEASE READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM

4. SITE(S) OR FACILITY(S) TO BE ACCESSED BY REQUESTOR

950 H STREET

RDS

TSD

WFO

JJRTC

1111 18TH STREET

7. POSITION TO BE HELD OR DUTIES TO BE PERFORMED

5. FREQUENCY OF ACCESS REQUIRED (check one)

YES NO

OTHERMONTHLYWEEKLYDAILY

6. LENGTH OF WORK TO BE PERFORMED, OR DURATION OF ACCESS

0 - 3 months 3 - 6 months 1 year 2 years

Form Approved: O.M.B. Control No. 1620-0002, Expiration Date: 08/31/2016

SSDV STREET

OTHER:

CONTRACTOR DETAILEE/JDA GOVERNMENT EMPLOYEE OUTSIDE OF THE SECRET SERVICE

(frequent visitor for official business)

OTHER:

8. USSS CONTRACT NUMBER (required for all contractors)

10. FOR DETAILEES WITHOUT A SECURITY CLEARANCE, OR FOR CONTRACTORS PERFORMING WORK ON UNCLASSIFIED CONTRACTS, PLEASE INDICATE THE POSITION SENSITIVITY LEVEL BELOW. (For detailees with a security clearance, or for contractors performing work on classified USSS contracts, skip this section and go directly to item 11.)

NON-IT POSITION RISK LEVEL: LOW RISK* (1N) MODERATE RISK (5N) HIGH RISK (6N)

IT POSITION RISK LEVEL: MODERATE RISK (5C) HIGH RISK (6C)

Instructions: A DD-254 form is required for all contractor positions requiring a security clearance. By selecting "YES" in the "DD-254 ON FILE?" box below, you are verifying that a DD-254 is on file for the contract identified above (DD-254 requirements are not applicable for detailees). For positions not requiring a clearance, please indicate a Position Sensitivity Level in item 10 above.

11. FOR DETAILESS WITH A SECURITY CLEARANCE, OR FOR CLASSIFIED CONTRACTS, PLEASE INDICATE THE POSITION SECURITY CLEARANCE REQUIREMENT BELOW.

(This item should be completed for contractors related to a USSS classified contract; or for detailees who possess the appropriate security clearance.)

SECURITY CLEARANCE LEVEL REQUIRED: SECRET (2C/2N) TOP SECRET (3C/3N) YES

SECTION B CONTINUES ON PAGE 2

Instructions: One of the six boxes must be selected for every applicant that is requesting regular, unclassified access. For example, if a contractor or detailee is performing services for the USSS other than IT support, it must be either 1N, 5N, or 6N based on how sensitive their role is; however, for those who provide IT development, IT engineering, or IT administration support for TEC, IRM, CIO, etc., then 5C or 6C would be required. *Low Risk (1N/1C) is for building access only, where there will be no access to USSS IT systems or sensitive program areas. Check only one box.

LOW RISK* (1C)

Company name:

Street address:

City, State, ZIP:

The estimated average burden associated with this collection of information is Comments and or suggestions concerning the accuracy of this burden estimate and for reducing this burden should be directed to the Secret Service at this address: Communications Center (MNO), 245 Murray Lane, SW, Building T5, Washington, DC 20223; and to the Office of Management and Budget, Paperwork Reduction Project (1620-0002), Washington, DC 20503.

In accordance with 5 CFR 1320.5(b), a Government agency may not conduct or sponsor, and a person is not required to complete, a collection of information unless the collection of information displays a valid OMB control number.

INSTRUCTIONS:

1. Please TYPE or PRINT clearly with a dark ball point pen.

2. To apply for access into U.S. Secret Service controlled facilities, the applicant must complete this form in its entirety. (Failure to properly complete this form can result in delays and/or non admittance into U.S.

Secret Service controlled facilities.) Note that the applicant must sign this form TWICE: once under the release statement and again at item 21.

3. A representative from the U.S. Secret Service Responsible Office should submit this completed form to the U.S.

Secret Service Security Clearance Division at least five days prior to the anticipated access date.

4. If there are any questions regarding this form, please contact the Security Clearance Division at (202) 406-6658.

PUBLIC BURDEN INFORMATION

minutes per respondent or recordkeeper.15

Page 2 of 2SSF 3237 (Rev. 08/2013)

Form Approved: O.M.B. Control No. 1620-0002, Expiration Date: 08/31/2016

Privacy Act Statement: All information requested on the U.S. Secret Service Facility Access Request is collected under authority derived from 18 U.S.C. 3056 and Executive Order 9397. The routine uses of information requested include referral to other Federal, State and Local agencies for determining suitability for access to secure areas, and/or sensitive, unclassified material of the U.S. Secret Service. Submission of the information is voluntary, however, failure to provide information requested may prohibit processing and cause denial of access to secure areas or sensitive material protected by the U.S. Secret Service. Disclosure of your Social Security Account Number is voluntary. The information is used to identify and separate individuals with similar or identical names or initials.

Refusal to disclose your Social Security Number will be no cause for denial of any right, benefit or privilege provided by law.

This authorization is given in connection with the investigative procedures being conducted relative to my contractual services with the U.S. Secret Service, and/or access to secure areas occupied by the U.S. Secret Service.

(signature of applicant)

19. HAVE YOU EVER BEEN CONVICTED OF ANY

CRIMINAL OFFENSE?

20. ARE THERE ANY PENDING CHARGES AGAINST YOU

BEFORE A CIVIL OR CRIMINAL COURT?

18. HAVE YOU EVER BEEN ARRESTED, CHARGED, OR

INDICTED FOR A CRIME?

NOTE: I understand than any false statement on any part of my application may be grounds for denying me access into Secret Service controlled facilities, and/or grounds for prosecution under Title 18 U.S.C. 1001.

22. DATE21. SIGNATURE OF APPLICANT

RELEASE STATEMENT - TO BE COMPLETED BY APPLICANT

This release when presented by a duly authorized representative of the U. S. Secret Service will constitute my consent and authority to obtain any information relating to my activities from criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail businesses, or other sources of information. The information may include my criminal history record information and financial and credit information.

Specifically, I hereby authorize the release of Federal/State/Local Police & Criminal Records or data to the U.S. Secret Service by applying my signature on the designated line below.

My signature further authorizes the U.S. Secret Service (or other component o f the Department of Homeland Security) to obtain one o r more consumer cred it reports about me pursuant to the Fair Credit Reporting Act from any consumer credit reporting agency. Copies of this authorization that show my signature are as valid as the original signed by me.

YES NO YES NO YES NO

SECTION B - CONTINUED FROM PAGE 1