Attachment J-15 CATBPSS TSIF Access Forms.docx

RFP HSTS04-11-R-CT2042

Attachment J.15

CONTRACTOR INFORMATION WORKSHEET

Please complete the following information and submit along with your Security Packet to the Office of Security, Personnel Security Division. Please have your COTR provide you with the information required for this worksheet.

Contracting Company Name & Address:

Applicant Name:

Contracting Officer Name: Lance Nyman

Contracting Officer Phone #: 571-227-4261 Contract #:

Contract Expiration Date:

Work location (check one): TSA HQ_____X (TSIF)___________

Field ___________________

TSA Incoming Visit Request

(VAL)

(SAMPLE ONLY)

In order to comply with TSA security policies and procedures, the following information must be faxed to the TSA Office of Security, Personnel Security Division’s Customer Service Unit (CSU) 48 hours prior to the start of your TSA event. Please address all requests to CSU, fax number (571) 227-1903. If you have any questions regarding the requested information, please contact ps.csu@dhs.gov

* Please ensure the incoming visit requests are faxed by the agency/ company’s security office on their letterhead (with address).

Required Information for all events

· Attendee’s full legal name (last, first, MI)

· Citizenship

· SSN

· DOB

· POB (City & state, or city & country if outside US)

· Clearance level and date

· Clearance granting agency

· Type of investigation and close date

· Contract number (if applicable)

· Contract number start/end date (if applicable)

· TSA POC/phone number

· Date(s) of visit (up to one year, but not to exceed contract expiration)

· Purpose of visit

· Indicate which TSA facility to be visited

ALL VISIT REQUESTS MUST BE SIGNED BY THE SECURITY OFFICER

Please bring picture ID to present to the guard upon arrival at the TSA visitor center and if an access badge is required please contact your POC or COTR for additional paperwork.

Fair Credit Reporting Act Authorization

INSTRUCTIONS: Carefully read this authorization to release information about you, then type or print legibly and complete all applicable sections. Return original completed form to TSA Office of Security, Personnel Security Division.

Information provided by you on this form will be furnished to a consumer reporting agency in order to obtain information in connection with an investigation to determine your (1) fitness for Federal employment, (2) clearance to perform contractual service for the Federal Government, and/or (3) security clearance or access. The information obtained may be disclosed to other Federal agencies for the above purposes and in fulfillment of official responsibilities to the extent that the law permits such disclosure.

I hereby authorize TSA to obtain such report(s) from any consumer reporting agency for employment purposes.

Full Name

Mother’s Maiden Name

Social Security Number

Are you a U.S. Citizen?

|_| Yes |_| No Permanent Resident Number (If applicable)

Date of Birth (mm/dd/yyyy)

Place of Birth (City/State)

County of Birth (If born in the U.S.)

Current Address

City

State

Zip

If at current address less than 2 years, please enter former address.

Former Address

City

State

Zip

Signature (sign in ink)

Date Signed (mm/dd/yyyy)

Note: Please take notice that one or more consumer credit reports may be obtained for employment purposes pursuant to the Fair Credit Reporting Act, as amended,15 U.S.C., § , et seq. Should a decision to take any adverse action against you be made based either in whole or in part on the consumer credit report, the consumer reporting agency that provided the report played no role in the agency’s decision to take such adverse action.

PRIVACY ACT STATEMENT: Authority: 49 U.S.C. § 114 (n); 15 U.S.C. § 1681b; E.O. 9397. Principal Purpose(s): To obtain a copy of your credit report in order to determine your suitability for employment in the position for which you are being considered. Routine Use(s): This information will be shared with consumer reporting agencies for the purpose of obtaining your credit report, or for routine uses listed in the applicable system of records notice. Disclosure: Disclosure of the requested information is voluntary in the sense that no criminal penalties will follow from a failure to provide the information. However, failure to provide the requested information may affect your employment prospects, eligibility for continued employment, ability to obtain a security clearance, or ability to work on a government contract. Disclosure of your SSN is also voluntary, but failure to provide your SSN may result in a delay in determining your suitability for employment.

Authorization for Release of Information

INSTRUCTIONS: Carefully read this authorization to release information about you, then type or print legibly and complete all applicable sections. Return original completed form to TSA Office of Security, Personnel Security Division.

I authorize the Transportation Security Administration (TSA), through its employees, agents, or contractors, to obtain any information relating to my activities from criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, or other relevant sources of information. This information may include, but is not limited to, any criminal history record information, and financial and credit information.

I understand that the purpose of this authorization is to permit TSA to conduct a background investigation for the purpose of making a determination of suitability or eligibility for employment and/or a security clearance, or for work on a Government contract. I authorize the custodians of records and other sources of information pertaining to me to release such information upon request of TSA, regardless of any previous agreement to the contrary. I understand that the information released by custodians of records and other sources of information is for official use by the Federal Government only for the purposes stated above. This information may be re-disclosed by the Government only as authorized by law.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for five (5) years from the date signed or upon the termination of my affiliation with the Federal Government, whichever is sooner.

Full Name

Other Names Used

Social Security Number

Current Address

City

State

Zip

Contact Number

Signature (sign in ink)

Date Signed (mm/dd/yyyy)

PRIVACY ACT STATEMENT: Authority: 49 U.S.C. § 114 (n); E.O. 9397. Principal Purpose(s): To establish that applicants and incumbents either employed by TSA or working under contract are suitable for the job and/or eligible for a public trust or sensitive position, and/or a security clearance. Routine Use(s): This information may be shared with to any potential source from which information is requested in the course of this background investigation to the extent necessary to identify you, inform the source of the nature and purpose of the investigation, and to identify the type of information, or for routine uses listed in the applicable system of records notice. Disclosure: Disclosure of the requested information is voluntary in the sense that no criminal penalties will follow from a failure to provide the information. However, failure to provide the requested information may affect your employment prospects, eligibility for continued employment, ability to obtain a security clearance, or ability to work on a government contract. Disclosure of your SSN is also voluntary, but failure to provide your SSN may result in a delay in determining your suitability for employment.

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