PSIP Request.pdf

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Latvia Liaison Analyst - base + 4 option periods
Solicitation number
W912JB-26-Q-A006
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This is a Personnel Security Investigation Request form used by the Department of Defense to initiate background investigations for individuals requiring security clearances. The form collects applicant information including name, Social Security number, date of birth, citizenship status, and contact details. Applicants must designate their employment status as military, civilian, or contractor and provide their grade or position level.

The form requires supervisors to justify the investigation through one of three methods: citing a military occupational specialty (MOS) code, referencing an attached DD Form 2875 position description, or providing specific details of the requirement. Requestors must specify whether the investigation is initial, periodic reinvestigation, or interim in nature, and indicate whether fingerprint appointment scheduling is necessary. The supervisor certifying the request must confirm the individual requires the background investigation for valid employment or mission requirements. The document is governed by authority from 10 U.S.C. 3013, 50 U.S.C. 4039, the National Security Act of 1947, and Executive Orders 10450, 10865, and 9397, with disclosure of Social Security numbers being voluntary but failure to provide may result in access denial.

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Attachment B - Solicitation Provisions and Clauses.pdf PDF
Attachment A - PWS.pdf PDF

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Personnel Security Investigation Request

Privacy Act Statement Authority: 10 U.S.C. 3013, 50 U.S.C. 4039, and the National Security Act of 1947; E.O 10450 and 10865; and E.O. 9397 (SSN).

Principle Purpose(s): To obtain or retain a security clearance.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:

Information may be released to federal agencies based on formal accreditation as specified in official directive, regulations, and demonstrated need-to-know; to federal, state, local, and foreign law enforcement, intelligence, or security agencies in connection with a lawful investigation under their jurisdiction; and to commanders/agency heads for adverse personnel actions.

The DoD 'Blanket Routine Uses' set forth at the beginning of the Army's compilation of systems of records notices also apply to this system.

Disclosure: Disclosure of SSN is voluntary; however, failure to provide SSN may result in access being denied.

APPLICANT INFORMATION

SSN: □ MILITARY □ CIVILIAN □ CONT RACT OR

GRADE:

LAST NAME: FIRST: MIDDLE:

SUFFIX (Sr.,Jr.,I, II, etc.): DATE OF BIRTH (MM/DD/YYYY):

COUNTRY OF BIRTH: STATE OF BIRTH: CITY OF BIRTH:

U.S. CITIZEN: YES □ NO □

VERIFICATION :

DOCUMENT NUMBER:

PCS DATE: ETS DATE: RETIREMENT DATE:

UNIT/ORGANIZATION/COMPANY:

PRIMARY E-MAIL (OFFICIAL (.MIL) RECOMMENDED):

ALTERNATE E-MAIL:

PRIMARY PHONE#: ALTERNATE PHONE#:

ACTION REQUESTED

INVESTIGATION REQUIRED:

PERIODIC REINVESTIGATION:

YES □ NO □

INTERIM REQUIRED:

YES □ NO □

FINGERPRINT INFORMATION

FINGERPRINT APPOINTMENT (ONLY REQUIRED FOR INITIAL CLEARANCES):

WITH: DATE: TIME:_______________________________

JUSTIFICATION/REASON FOR INVESTIGATION

□ MOS CODE (MILITARY ONLY) (e.g., 96B):

□ POSITION DESCRIPTION/DD2875(ATTACHED)

□ OTHER (PROVIDE SPECIFIC DETAILS OF THE REQUIREMENT):

SUPERVISOR INFORMATION

SUPERVISOR RANK: FIRST NAME: LAST NAME:

TITLE: EMAIL ADDRESS:

PHONE: REMARKS:

I certify that this individual requires the background investigation for valid employment offer or mission requirements.

SIGNATURE:

kelvin.green Typewritten Text kelvin.green Typewritten Text

SSN:
MILITARY: Off
CIVILIAN: Off
C ON T RA CT OR: Off
GRA DE:
LAST NAME:
FIRST:
MIDDLE:
SUFFIX SrJrI II etc:
DATE OF BIRTH MMDDYYYY:
COUNTRY OF BIRTH:
STATE OF BIRTH:
CITY OF BIRTH:
DOCUMENT NUMBER:
UNITORGANIZATIONCOMPANY:
PRIMARY EMAIL OFFICIAL MIL RECOMMENDED:
ALTERNATE EMAIL:
PRIMARY PHONE:
ALTERNATE PHONE:
OTHER PROVIDE SPECIFIC DETAILS OF THE REQUIREMENT:
SUPERVISOR RANK:
TITLE:
EMAIL ADDRESS:
PHONE:
REMARKS:
US_NO: Off
us-yes: Off
FP_WITH:
FP_DATE:
FT_TIME:
MOS CODE:
MOS: Off
PR-YES: Off
PR-NO: Off
INTERIM-YES: Off
INTERIM_NO: Off
PD: Off
OTHER: Off
SUP_FIRST NAME:
SUP_LAST NAME_2:
ETS:
PCS:
RETIRE:
PHONE_1: [CELL]
PHONE_2: [CELL]
INVESTIGATION: [SELECT ONE]
BIRTH: [BIRTH CERTIFICATE]

File details come from the government source that posted it. Updated .