Request For Passing A Security Clearance Form - Us Department Of Agriculture
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1United States Department of Agriculture
PERSONNEL AND DOCUMENT SECURITY DIVISION
REQUEST FOR PASSING A SECURITY CLEARANCE
(PDSD requires 24 hours for internal requests, and 72 hours for external requests)
1. Name of Requestor (Last, First, MI)
2. Date
3. USDA Agency
4. Work Email
5. Work Phone
6. Name of supervisor authorizing PDSD to pass the clearance for the requestor
(Printed Name)
7. Supervisor Signature
8. Date
Please complete this form in its entirety and submit to PDSD/CNSPB/SSO
either by fax at (202) 720-1689, or email at pdsd@dm.usda.gov.
Contact PDSD at (202) 720-7373 if you have any questions.
Failure to complete all information may result in processing delays.
9. Name of individual who needs clearance passed (Last, First, MI)
10. SSN
11. DOB
(Last 4 Only)
12. Organization and Location of Visit
13. Date(s) of Visit
From:
To:
14. Clearance Level Required for the Event (check one)
Confidential
Secret
Top Secret
15. Is SCI Access required?
Yes
No
(If yes – list accesses here) _________________________________________________________
Information for Organization being visited
16. POC Name
17. POC Phone (unsecure)
18. Security POC Name
19. Security POC Phone (unsecure)
20. Security Office Fax # or Email (unsecure)
21. Reason for visit (meeting title, conference title, etc.)
22. Will the individual be making frequent visits to this facility during the year?
Yes
No
NOTICE: The Privacy Act, 5 U.S.C. 552a, requires that federal agencies inform individuals at the time information is solicited
from them, whether the disclosure is mandatory or voluntary, by what authority such information is solicited, and what uses will
be made of the information. You are hereby advised that authority for soliciting your Social Security Number (SSN) is
Executive Order 9397. Your SSN is needed to keep records accurate because other people many have the same name and birth
date. Your SSN will be used to identify you precisely when it is necessary to certify that you have access as indicated above.
Although disclosure of your SSN is not mandatory, your failure to do so may impede the processing of such clearance
verifications and passing.
(Rev. 02/15)
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