Key Management Personnel - CDSE
OFFICIAL USE ONLY (WHEN COMPLETED)
KEY MANAGEMENT PERSONNEL (KMP)
LEGAL COMPANY NAME AND PHYSICAL ADDRESS OF FACILITY LOCATION:
(NOTE: SEE INSTRUCTIONS REGARDING COMPLETING THIS FORM)
Date Completed:
OFFICIAL USE ONLY (WHEN COMPLETED)
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| | |DATE/PLACE OF BIRTH (CITY/STATE)/ | |IDENTIFY INDIVIDUAL’S SECURITY CLEARANCE(S), LEVEL,|
|INDIVIDUAL’S COMPLETE NAME |ALL COMPANY TITLES/POSITIONS HELD BY IDENTIFIED |CITIZENSHIP (U.S., OTHER, DUAL) |SOCIAL SECURITY NUMBER |ISSUING U.S. |
| |INDIVIDUAL | | |GOVERNMENT AGENCY(ies) OR EXCLUSION AND DATE |
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SAMPLE ONLY –COMPLETE & SUBMIT THIS FORM IN e-FCL
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