ssf3237.pdf

14. LENGTH OF TIME YOU

WORKED FOR THIS

EMPLOYER

Years

Months

20. ARE THERE ANY PENDING CHARGES AGAINST YOU

BEFORE A CIVIL OR CRIMINAL COURT?

5. USSS CONTRACT NUMBER (required for all contractors)

4. COMPANY/AGENCY AND POSITION TO BE HELD OR OTHER DUTIES PERFORMED

16. DO YOU HOLD U.S. CITIZENSHIP STATUS?

DOES THE APPLICANT HAVE A DD-254 ON FILE?

7. TYPE OF APPLICANT

17. IF YOU ARE A U.S. CITIZEN OTHER THAN BY BIRTH, PROVIDE THE FOLLOWING:

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

12. TELEPHONE (area code, number)10. PRESENT ADDRESS (street address, city, state, zip code) 11. DO YOU HAVE AN

UNEXPIRED DHS PIV

CARD?

Work:

YES

Residence:

NO

Cellular:

15. NAME OF SUPERVISOR AND TELEPHONE NUMBER (with area code)13. NAME AND ADDRESS OF EMPLOYER (company/agency)

Naturalization Certificate No.:

Date of Issuance:

Page 1 of 2SSF 3237 (Rev. 07/2015)

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

1. NAME OF USSS RESPONSIBLE

OFFICE

3. CONTACT'S USSS E-MAIL ADDRESS

SECTION B - TO BE COMPLETED BY APPLICANT

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

6. IS THIS A CLASSIFIED PROGRAM/CONTRACT?

YES NO

NO

YES NO

Form Approved: O.M.B. Control No. 1620-0002, Expiration Date: pending review

CONTRACTOR DETAILEE/JDA GOVERNMENT EMPLOYEE OUTSIDE OF THE SECRET

SERVICE (frequent visitor for official business)

OTHER:

8. SPECIFY THE TYPE OF ACCESS THAT THIS APPLICANT REQUIRES (you must select one category):

CATEGORY 1 (NON ROUTINE FACILITY ACCESS/ NO ACCESS TO INFORMATION TECHNOLOGY (IT) /NO ACCESS TO PERSONALLY

IDENTIFIABLE INFORMATION (PII)).

CATEGORY 1 ACCESS GRANTS THE APPLICANT TWO YEAR ACCESS.

IF LESS THAN TWO YEARS ACCESS, PLEASE INDICATE ACCESS EXPIRATION DATE:

YES

SECTION B CONTINUES ON PAGE 2

Company name:

Street address:

City, State, ZIP:

CATEGORY 2 (ROUTINE FACILITY ACCESS AND NO IT ACCESS OR ACCESS TO PII).

CATEGORY 2 ACCESS GRANTS THE APPLICANT FIVE YEAR ACCESS.

IF LESS THAN FIVE YEARS ACCESS, PLEASE INDICATE ACCESS EXPIRATION DATE:

CATEGORY 3 (IT ACCESS AND/OR ACCESS TO PII REGARDLESS OF FACILITY ACCESS).

CATEGORY 3 ACCESS GRANTS THE APPLICANT FIVE YEAR ACCESS.

IF LESS THAN FIVE YEARS ACCESS, PLEASE INDICATE ACCESS EXPIRATION DATE:

19. HAVE YOU EVER BEEN CONVICTED OF ANY

CRIMINAL OFFENSE?

18. HAVE YOU EVER BEEN ARRESTED, CHARGED,

OR INDICTED FOR A CRIME?

YES NO YES NO YES NO

2. NAME OF USSS POINT OF CONTACT (Last, First, Middle)

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.

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.

PUBLIC BURDEN INFORMATION

minutes per respondent or recordkeeper.15

Page 2 of 2SSF 3237 (Rev. 07/2015)

Form Approved: O.M.B. Control No. 1620-0002, Expiration Date: pending review

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.

SECTION B - CONTINUED FROM PAGE 1

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)

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 of the Department of Homeland Security) to obtain one or more consumer credit 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.

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.)

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

Secret Service Security Clearance Division at least five business days prior to the anticipated access date for Category 1 applicants. For Category 2 and Category 3 applicants, the USSS responsible office must submit this completed form to the Security Clearance Division at least 10 business days prior to the anticipated access date.

4. A DD-254 form is required for all contractor positions requiring a security clearance. By selecting "YES" for Section A, Item 9, you are verifying that a DD-254 is on file for the contract identified in Section A, Item 5 (DD-254 requirements are not applicable for detailees).

5. Note that the applicant must sign this form TWICE: once under the release statement at the top of this page, and again at item 21.

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