Onesaf Ide Account Request Form

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OneSAF IDE Account Request
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 the 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.
TYPE OF REQUEST
INITIAL
MODIFICATION
DEACTIVATE
SYSTEM NAME
LOCATION (Physical Location of System)
OneSAF IDE
IDE Facility
PART I (To be completed by Requestor)
1. NAME (Last, First, Middle Initial)
2. ORGANIZATION
3. OFFICE SYMBOL/DEPARTMENT
4. PHONE (Commercial / DSN)
5. OFFICIAL E-MAIL ADDRESS
6. SERVICE REQUESTED
7. OFFICIAL MAILING ADDRESS
8. CITIZENSHIP
9. DESIGNATION OF PERSON
MILITARY
CIVILIAN
US
FN
OTHER
CONTRACTOR
10. IA TRAINING AND AWARENESS CERTIFICATION REQUIREMENTS
I have completed Annual Information Awareness Training.
DATE (YYYYMMDD)
12. DATE (YYYYMMDD)
11. USER SIGNATURE
PART II - ENDORSMENT OF ACCESS BY GOVERNMENT SPONSOR OR SUPERVISOR (If individual is a contractor - provide company
name, contract number, and date of contract expiration in Block 16.)
13. JUSTIFICATION FOR ACCESS
16. ACCESS EXPIRATION DATE (Contractors must specify Company Name, Contract Number, Expiration Date. Use Block 27 if needed.)
17. SPONSOR NAME (Print Name)
18. SPONSOR SIGNATURE
19. DATE (YYYYMMDD)
20b. PHON E NUMBER
20. SPONSOR ORGANIZATION/DEPARTMENT
20a. SPONSOR E-MAIL ADDRESS
PART III – ACCOUNT APPROVAL (To be completed by OneSAF Program Government Personnel)
21. SIGNATURE OF INFORMATION OWNER/OPR
21a. PHONE NUMBER
21b. DATE (YYYYMMDD)
22. SIGNATURE OF IASO OR APPOINTEE
22a. PHONE NUMBER
22b. DATE (YYYYMMDD)

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