PRIVACY ACT STATEMENT AUTHORITY: PRINCIPAL PURPOSE(s): ROUTINE USE(s ...
CUI (when filled in)
REQUEST FOR SECURITY ACTION
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Section 3013, Secretary of the Army; AR 600-20, Army Command Policy; and E.O. 9397 (SSN). PRINCIPAL PURPOSE(s): Use this form to request an initial security verification, Classified Access, Periodic Reinvestigation, and/or Upgrade. ROUTINE USE(s): None. The "Request for Access" as set forth at the beginning of the Army's Compilation of Systems of Record Notices also applies to this system.
DISCLOSURE: Voluntary. However, failure to provide all the requested information could lead to rejection of compliant request for access. NOTE: This form contains Personally Identifiable Information (PII) when filled out, therefore, is protected as Controlled Unclassified Information (CUI). INSTRUCTIONS: Security Managers complete Sections 1 - 5.
SECTION 1: APPLICANT INFORMATION
RANK/GRADE/NAME (Last, First, Middle):
SSN:
DATE OF BIRTH:
CITY OF BIRTH:
STATE OF BIRTH:
COUNTRY OF BIRTH:
.MIL EMAIL ADDRESS (if no .mil, enter email):
PHONE:
OTHER:
PERSON CATEGORY:
STUDENT:
Military
Civilian
Contractor
Volunteer
Other
Yes
No School:
SECTION 2: INVESTIGATION & ACCESS REQUIREMENTS
Is this a Periodic Reinvestigation (PR)?
Yes
Is the applicant going to retire
No
or separate in the next 18 months?
Has the applicant been advised they
Yes
No have 2 weeks to complete eQIP?
Yes
No
WHAT DOES THE APPLICANT NEED? SELECT ALL THAT APPLY
In-process
Interim
Initial
COMMENTS: Medical
Out-process
Secret
Top Secret
LRC
Indoctrinate
Is there more than 2 years break in Federal Affiliated Service?
SECTION 3: CONTRACTORS
Contract #:
Task #:
Yes Company Name:
No
Date of last Federal Affiliated Service:
Contract Start Date: Contract End Date:
SECTION 4: CHILDCARE
Is this a childcare related position?
Yes
No
SECTION 5: SECURITY MANAGER ? I certify the information entered above is accurate, as reflected in the system of record.
DATE:
SIGNATURE:
PHONE:
No. Option Years:
SECURITY FORM 380-1, 20201211
Controlled By: Controlled By: Category: PRVCY Distribution/Dissemination Controls: FEDCON POC:
(Previous versions obsolete)
CUI (when filled in)
RESET
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