Attachment_3_-_Applicant_Data_Form.pdf

SECHQ1-12-R-T-002

Attachment 3

Office of Human Resources

Personnel Security

Applicant Data Form - Contractor

APPLICANT INFORMATION

Last Name First Name Full Middle

Name

Social Security Number

Date of Birth

Check here if… Middle Initial Only No Middle Name

Place of Birth City State Country

Are you a U.S. citizen? If not, citizenship?

Street Address

City State Zip Code

Phone Type of Phone Home

Email Address Division: Office Loc:

CONTRACT INFORMATION

Contractor Firm Contract Number

Contractor Project Mgr

Name:

Other Contractor Point of Contact

Name:

Phone: Phone:

SEC COTR

Name: SEC

Administrative Officer

Name:

Phone: Phone:

SEC Other

Name:

SEC Other

Name:

Phone: Phone:

TERM OF CONTRACT PERMANENT

(6 months or more)

(Check Box)

OR TEMPORARILY

(6 months or less)

(Check Box)

PREVIOUS INVESTIGATION INFORMATION

Does applicant have a previous background investigation? NO If yes, please complete section below.

Type of Investigation Date Investigation Completed

Type of Clearance Issued Date Clearance Issued

Security Manager Name Phone Number

SECHQ1-12-R-T-002

Attachment 3