Fillable Hq F 5631.2 - Request For Clearance Action printable pdf download

HQ F 5631.2

U.S. DEPARTMENT OF ENERGY

(01-99)

HEADQUARTERS CLEARANCE REQUEST AND NOTIFICATION

All Other Editions Are Obsolete

(Forward completed PART 1 with enclosures to Office of Safeguards and Security (OSS))

PRIVACY ACT STATEMENT ON REVERSE OF BLUE COPY

PART I - REQUEST FOR CLEARANCE ACTION

1. REQUESTOR

2. APPLICANT JOB TITLE/GRADE

3. APPLICANT

ROUTING SYMBOL

Human Resources

Headquarters Program Office

Inspector General

4. DATE OF REQUEST

5. APPLICANT DATA

6. APPLICANT STATUS

Full Name:

DOB:

DOE Employee/Consultant

SSN:

POB:

DOE Contractor/Consultant

Citizenship Status:

Other (Specify):

7. CONTRACTOR NAME:

SUBCONTRACTOR NAME:

(Complete name -- not initials)

Contract No:

Expiration Date:

8. CLEARANCE

9. SPECIAL PROCESSING

10. ACTION REQUESTED

REQUESTED

Reciprocity

Interim

Initial Clearance

Downgrade

Downgrade to BAO

AAAP

Upgrade

Extension

Reinvestigation

Reinstatement

Transfer

Cancellation

11. JUSTIFICATION: Identify the specific job activity requiring a clearance. Describe in detail the duties of the position and

ACCESS:

check

the highest level of classified information to be accessed, or list specific area access that is required.

FRD NSI

(Attach a separate sheet if required)

SNM

Applicant’s duty station:

Germantown

Forrestal

Other:

12. ENCLOSURES

13. I certify that U.S. Department of Energy (DOE) clearance is required in

order to perform official duties. Applicant

is not currently

SF-86, “Questionnaire for National Security Positions”

being processed for clearance by another agency.

OF 612, “Optional Application for Federal Employment” or Resume

Preemployment checks conducted and the applicant was found suitable

for employment.

OF 306, “Declaration for Federal Employment”

Routing Symbol

FP Cards (SF-87 Federal Employees/FD-258 Contractors)

HSO

DOE F 5631.18, “Security Acknowledgement”

DOE F 472.1. “Credit Release” (Fair Credit Reporting Act)

Results of Preemployment Checks

COR

DOE F 5631.21, “Security Badge Request”

Other (Specify):

ALL SIGNATURES MUST BE TYPED/PRINTED AND SIGNED

PART I I - CLEARANCE NOTIFICATION

1. DOE clearance has been:

Granted

Upgraded

Extended

Downgraded

Transferred

Reinstated

2. Effective date:

3. Case File No.

4. Applicant’s current clearance status:

Note: For DOE employees/consultants, it is the responsibility of the servicing Personnel Office to forward this information to the requesting office. For DOE

contractors/consultants, the requesting DOE program office will notify the contractor security official of this information. Notification to the individual may be

made orally; in no case will this notification be made to the individual in writing. Applicant will be provided with initial security briefing before being permitted

access to classified data or Special Nuclear Material (SNM). Written records of such initial and continuing briefings are required. Maintain this notification for

your records. If Individual terminates or transfers, notify the Personnel Security Program.

“Security Badge Request” Sent to: FORS

GTN

Date:

(Date Sent)

Manager, Personnel Security Program

White -- PSF

Blue -- Requestor

Pink -- Vault

Green -- Badge Office

Yellow -- Sender’s Suspense