Attachment_5E_PerSEC.pdf

v1. 06/2012

Section A: To Be Completed By the Applicant

1. Name (Last/Family) 2. First (Given) 3. Middle (or NMN) 4. Other Names Used 5. Suffix

6. Social Security Number 7. Date of Birth MM/DD/YYYY 8. Place of Birth (City and State) 9. Country 10. Gender

13. Daytime Phone Number 14. Cell Phone Number

15. Home Street Address 11. E-Mail Address (work) 12. E-Mail Address (personal)

16. City 17. State 18. Zip Code 19. Position (Job) Title

20. US Citizen?

24. Country of Citizenship

Non-US Born Citizens Only: Complete 22-24 as applicable

22. Naturalization Certificate Number 23. Alien Registration Number

Section B: To Be Completed By SEC Contract Officer Representative (COR)

1. Term of Service 4. Company Name (Prime) 8. Contract Number

U.S. SECURITIES AND EXCHANGE COMMISSION

100 F Street, N.E., Washington, DC 20549

REQUEST FOR PERSEC DETERMINATION (Contractors)

Comments (A separate sheet of paper can be included for comments if additional space is needed)

25. Prior Investigation? Prior Federal Investigation Only: Complete 26-28

26. Agency 27. Level of Investigation 28. Date of Completion

21. Naturalized Citizen?

5. Company Name (Sub-Contractor, if applicable)2. Division Supporting

Name:

All documentation must be submitted by the COR to the Personnel Security mailbox at personnelsecurity@sec.gov.

9. Contract End Date

Name:

6. Contract Program Manager

Name:

10. SEC COR

Name:

3. Physical Office Location (select one)

Phone:Phone:

7. Other Contract Point of Contact (if applicable) 11. Other SEC Point of Contact (if applicable)

Name:Name:

Phone:

Section C: Notes

Phone:

Long Term Temporary less than 6 months

Yes

Yes No

No

M F

ARO BRO CHRO DRO

FWRO LARO MIRO NYRO

PLRO SLRO SFRO HQ/OPC

Yes No No No Yes

Contractors