Dd Form 2835 - Program Access Request
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1CLASSIFICATION (When Filled In)
PROGRAM ACCESS REQUEST
PRIVACY ACT STATEMENT
s
AUTHORITY: 5 U.S.C. s7311; DoD 5200.2-R; and E.O. 9397.
PRINCIPAL PURPOSE(S): To obtain identity and security clearance/investigation status information for managing employee access to special access program (SAP)
information.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure to provide the requested information may delay processing or result in your being declared ineligible for access to SAP
information.
1. PROGRAM NAME
2. ACCESS LEVEL
3. BILLET POSITION
YES
NO
BILLET NUMBER:
4. NAME (Last, First, Middle Initial)
5. RANK/GRADE
6. SSN
7. DATE OF BIRTH
8. STATE/COUNTRY OF BIRTH
10. DATE NEEDED
(YYYYMMDD)
9. STATUS
(YYYYMMDD)
(X one)
MILITARY
CIVILIAN
CONTRACTOR
11. POSITION DESCRIPTION/JOB TITLE
12. POSITION TYPE
(X one)
TEMPORARY (Period of access:)
FULL TIME
PART TIME
13. ORGANIZATION/COMPANY NAME
14. ASSIGNMENT/JOB LOCATION
15. COMMAND/FACILITY ID CODE
(City and State)
16. SECURITY CLEARANCE
17. GRANTED BY
18. DATE GRANTED
19. INVESTIGATION TYPE
20. CONDUCTED BY
21. DATE COMPLETED
22. SECURITY INVESTIGATION STATUS
23. CENTRAL ADJUDICATION REVIEW
(X one)
(When required)
CONCUR
CONDUCTED BY:
IN PROGRESS
NOT STARTED (See Remarks)
CURRENT
NON-CONCUR
24. JUSTIFICATION (
) (Include the percentage of time to be spent supporting the program. Continue on separate sheet if necessary.)
(Classification)
25. REQUESTOR
(Functional Manager)
c.
a. TYPED NAME/TITLE/ORGANIZATION
b. SIGNATURE
d. DATE
(YYYYMMDD)
CONCUR
NON-CONCUR
26. ACTIVITY SECURITY MANAGER
(Government or Contractor)
c.
a. TYPED NAME/TITLE/ORGANIZATION
b. SIGNATURE
d. DATE
(YYYYMMDD)
CONCUR
NON-CONCUR
27. GOVERNMENT/CONTRACTOR PROGRAM MANAGER
c.
a. TYPED NAME/TITLE/ORGANIZATION
b. SIGNATURE
d. DATE
(YYYYMMDD)
CONCUR
NON-CONCUR
28. ADDITIONAL COORDINATION
(As required by the specific program)
c.
a. TYPED NAME/TITLE/ORGANIZATION
b. SIGNATURE
d. DATE
(YYYYMMDD)
(1)
CONCUR
NON-CONCUR
(2)
CONCUR
NON-CONCUR
(3)
CONCUR
NON-CONCUR
29. PSO
a. TYPED NAME/TITLE/ORGANIZATION
b. SIGNATURE
c. DCII
e. DATE
(OK or Referred to
d.
(YYYYMMDD)
CAO on YYYYMMDD)
CONCUR
NON-CONCUR
30. FINAL APPROVAL AUTHORITY
a. TYPED NAME/TITLE/ORGANIZATION
b. SIGNATURE
d. DATE
(YYYYMMDD)
c.
APPROVED
NOT
APPROVED
31. REMARKS/RESTRICTIONS
32. ATTACHMENTS
NOT REQD
ATTACHED
(Continue on separate sheet if necessary)
a. STANDARD FORM 86
b. LOCAL FILES CHECK (DCII)
c. FOREIGN ASSOCIATION
QUESTIONNAIRE
d. OTHER (LOC)
e. DERIVED FROM:
f. DECLASSIFY ON:
DD FORM 2835, DEC 2000
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