Attachment_J.11_-_TL_-_Contractor_Investigative_Request_Sep2016.pdf

PRIVACY ACT – FOR OFFICIAL USE ONLY

CONTRACTOR INVESTIGATIVE REQUEST

NAME: ____________________________________________ SSN: _________________________ Last Name, First Name MI

DOB: ________________ City/State OR City/Country of Birth:________________________________

DLA Distribution Site / DLA Distribution Directorate:_______________________________________

CONTRACT NUMBER:_______________________ COMPANY NAME:___________________________

The above named contractor requires the following designation in accordance with DLAI 8500.1 and DLAI 4314:

___ IT I

___ IT II

___ IT III

*Note: Clearances required for access to classified material and/or information are requested through the Contractor’s Cognizant Security Agency (CSA) and granted by the DoD Consolidated Adjudications Facility (DoD CAF), Industry Division.

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.

DI SECURITY SPECIALIST

DATE

“PRIVACY ACT INFORMATION”

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

Revision - September 2016

___ Installation Access Only

___ Secret Clearance*

___ Other: _______________

___ Child Care

___ AA & E Storage

___ ESS Maintenance