Fillable Tam Form 381 - System Authorization Access Request (Saar) printable pdf download

Tam Form 381 - System Authorization Access Request (Saar)

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SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)

PRIVACY ACT STATEMENT

AUTHORITY:

Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act.

PRINCIPAL PURPOSE:

To record names, signatures, and other identifiers for the purpose of validating trustworthiness

of individuals requesting access to Department of Defense (DoD) systems and information.

NOTE: Records may be maintained in both electronic and/or paper form.

ROUTINE USES:

None.

DISCLOSURE:

Disclosure of this information is voluntary; however, failure to provide the requested information

may impede, delay or prevent further processing of this request

DATE (YYYYMMDD )

TYPE OF REQUEST

INITIAL

MODIFICATION

DEACTIVATE

USER ID ___________________

SYSTEM NAME (Platform or Applications )

LOCATION (Physical Location of System)

SPS

APPMS

CEFMS Smartcard

PART 1 (To be completed by Requestor)

1. NAME (Last, First, Middle Initial)

2. SOCIAL SECURITY NUMBER

3. ORGANIZATION/LOCATION

4. OFFICE SYMBOL/DEPARTMENT

5. PHONE (DSN OR Commercial)

6. OFFICIAL E-MAIL ADDRESS

7. JOB TITLE AND GRADE/RANK

8. OFFICAL MAILING ADDRESS

9. CITIZENSHIP

10. DESIGNATION OF PERSON

MILITARY

CIVILIAN

OTHER

CONTRACTOR

11. IA TRAINING AND AWARENESS CERTIFICATION REQUIREMENTS (Complete as required for user or functional level access)

DATE (YYYYMMDD )____________________

I have completed Annual Information Awareness Training

13. DATE (YYYYMMDD )

12. USER SIGNATURE

PART II - ENDORSEMENT OF ACCESS BY INFORMATION OWNER, USER SUPERVISOR OR GOVERNMENT SPONSOR

(if individual is a contractor - provide company name, contract number, and date of contract expiration in Block 17.)

14. JUSTIFICATION FOR ACCESS

14a. DATE OF BIRTH (YYYYMMDD )____________________

PLACE OF BIRTH:____________________________

IRAQI LOCAL NATIONAL OR AFGHANISTAN LOCAL NATIONAL DOSSIER #______________________________________________

15. TYPE OF ACCESS REQUIRED:

AUTHORIZED

PRIVILEGED

16. USER REQUIRES ACCESS TO:

UNCLASSIFIED

OTHER_____________________________________________________________________

17a. ACCESS EXPIRATION DATE (Contractors must specify Company

17. VERIFICATION OF NEED TO KNOW

Name, Contract Number, Expiration Date. Use Block 27 if needed.)

Supervisor MUST Initial Here__________

I certify that this user requires access as requested.

18. SUPERVISOR'S NAME (Print Name )

20. DATE (YYYYMMDD )

19. SUPERVISOR'S SIGNATURE

21. SUPERVISOR'S ORGANIZATION/DEPARTMENT

21a. SUPERVISOR'S E-MAIL ADDRESS

21b. PHONE NUMBER

22b. DATE (YYYYMMDD )

22. SIGNATURE OF INFORMATION OWNER/OPR

22a. PHONE NUMBER

26. DATE (YYYYMMDD )

23. SIGNATURE OF IAO OR APPOINTEE

24. ORGANIZATION/DEPARTMENT

25. PHONE NUMBER

TAM Form 381, MAR 2011

Tam Form 381 - System Authorization Access Request (Saar)

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