PSIP Investigation request sheet.pdf
PDF 136 KB Posted
- Attached to
- Poland Liaison - ILARNG Federal contract opportunity
- Solicitation number
- W91SMC24R0006
- Issued by
- Department of the Army National Guard
About this file
This document is a Request for PSIP (Personnel Security Investigation Program) Investigation form. It requests the initiation of a security clearance investigation for an individual with details such as name, social security number, date of birth, citizenship status, contact information, and the reason for the security clearance request.
The related federal contract opportunity is for a Service-disabled veteran-owned small business (SDVOSB) set-aside, single Firm Fixed Price contract to provide professional liaison services for the Illinois National Guard in the Republic of Poland. The contract period is from September 29, 2024, to September 30, 2025. The contractor will be responsible for providing all necessary personnel, equipment, tools, materials, supervision, and quality control to perform the required services, as defined in the Performance Work Statement (PWS). The solicitation number is W91SMC24R0006, and the contracting agency is the Department of the Army National Guard.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Answers to question - W91SMC24R0006 Poland Liasion.pdf | ||
| Employee Guidelines.pdf | ||
| W91SMC24R0006 - Poland Liaison Solicitation.pdf | ||
| DD254 Poland.pdf | ||
| DD254-Instructions.pdf |
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Text version
Military Civilian Contractor
Top Secret Secret Suitability/Network
IT Level I IT Level II
IT Level III
None
Periodic Reinvestigation Yes No
Reason for Access ____________________________________MOS _____
Last _____________ First _____________Middle____________ Initial Only No Middle Name
US Citizen Yes No
Unit of Assignment___________________ UIC ____________
Country of Birth ___________State of Birth_______City of Birth________________________ (Provide Correct Spelling)
Expedite Request Yes No Reason _________________________________________
Interim Clearance Required Yes No Justification_______________________________
S2/Security Manager Email Address (Enterprise Preferred) ______________________
Primary Phone Number ________________________ (Check one) Com___DSN___Cell___
Secondary Phone Number_______________________ (Check one) Com___DSN___Cell___
One of the below listed documents will be used to verify US citizenship
S2/Security Manager will review one of the following documents:
US Birth Certificate Registration Number ____________
US Passport Registration Number, Date and Location where issued ________________________________________ Certificate of Naturalization, Registration Number, Date, Court and Location Issued_____________________________________
Department of State, Consular Report of Birth FS 240, Registration Number_____________________________ Department of State, Certification of Birth, FS 545/DS1350, Registration Number ___________________________ Certificate of Citizenship (born abroad to a U.S. citizen parent or parents), Registration Number ______________________
Applicant Preferred Email Address _____________________________________________
Applicant Email Address (Secondary email) ___________________________
Supervisor Email Address (Enterprise Preferred) ___________________________
Primary Phone Number _________________________ (check one) Com___DSN___Cell___ Secondary Phone Number________________________ (check one) Com___DSN___Cell___
NOTICE: After security receives this form, you will be contacted by the ARMY Center of Excellence by the email provided above with specific instructions to start your required background investigation.
SECURITY OFFICE USE ONLY:
SECRET TOP SECRETClearance required (attach Justification):
Initiated By: Date Initiated: PSIP Ticket No# CLR
FOR OFFICIAL USE ONLY // PRIVACY ACT PROTECTION REQUIRED
REQUEST FOR PSIP INVESTIGATION
Rank _________
SSN ____________________ DOB DD/MM/YYYY ______________
Check One: Ms. Mrs. Miss. Mr. Suffix: _______ usarmy.jackson.CAC.mbx.usad-security@mail.mil
803) 751-5346
803) 751-3566
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File details come from the government source that posted it. Updated .