Attachment_9_-_Contractor_Investigative_Request.pdf

PRIVACY ACT – FOR OFFICIAL USE ONLY

SP3300-15-R-5007

Attachment 9 – Contractor Investigative Request

“PRIVACY ACT INFORMATION”

In compliance with the Privacy Act of 1974, this information is Personal Data must be protected from public disclosure.

CONTRACTOR INVESTIGATIVE REQUEST

NAME: ________________________________________ SSN:__________________________________ Last First Middle

DOB: ___________________________ City/State and Country of Birth: ______________________

ORGANIZATION/OFFICE SYMBOL: _____________________________________________________

CONTRACT NUMBER/COMPANY NAME: _______________________________________________

The above named contractor requires the following designation in accordance with DLAD 8500.6 and DLAR 5200.11:

___ IT I ____ Unescorted Entry

___ IT II ____ Installation Access

___ IT III ____ Child Care Provider

___ Secret Clearance (SEE NOTE) ____ Access to Restricted Area (Unclassified)

Note: Clearances required for access to classified material and/or information are requested through the Contractor’s Cognizant Security Agency (CSA) and granted by DISCO (Defense Industrial Security Clearance Office).

REQUESTING OFFICIAL DATE

VALIDATION OF REQUEST

TO: _________________ FROM: DLA Intelligence (New Cumberland)

____ The requested determination has been processed and all necessary investigative requirements have been met.

Type Investigation Completed: ___________________ Eligibility Level: ____________________

Investigation Completion Date: ___________________ Date Granted: ____________________

____ Unfavorable determination has been made. Access eligibility is denied.

Security Specialist Signature Date