Dd Form 2875 - System Authorization Access Request (Saar)
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3SYSTEM 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 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
DATE (YYYYMMDD)
INITIAL
MODIFICATION
DEACTIVATE
USER ID
SYSTEM NAME (Platform or Applications)
LOCATION (Physical Location of System)
PART I (To be completed by Requestor)
1. NAME (Last, First, Middle Initial)
2. ORGANIZATION
3. OFFICE SYMBOL/DEPARTMENT
4. PHONE (DSN or Commercial)
5. OFFICIAL E-MAIL ADDRESS
6. JOB TITLE AND GRADE/RANK
7. OFFICIAL MAILING ADDRESS
8. CITIZENSHIP
9. DESIGNATION OF PERSON
MILITARY
CIVILIAN
US
FN
OTHER
CONTRACTOR
10. IA TRAINING AND AWARENESS CERTIFICATION REQUIREMENTS (Complete as required for user or functional level access.)
I have completed Annual Information Awareness Training.
DATE (YYYYMMDD)
12. DATE (YYYYMMDD)
11. 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 16.)
13. JUSTIFICATION FOR ACCESS
14. TYPE OF ACCESS REQUIRED:
AUTHORIZED
PRIVILEGED
15. USER REQUIRES ACCESS TO:
UNCLASSIFIED
CLASSIFIED (Specify category)
OTHER
16a. ACCESS EXPIRATION DATE (Contractors must specify Company Name,
16. VERIFICATION OF NEED TO KNOW
Contract Number, Expiration Date. Use Block 27 if needed.)
I certify that this user requires access as requested.
17. SUPERVISOR'S NAME (Print Name)
18. SUPERVISOR'S SIGNATURE
19. DATE (YYYYMMDD)
20b. PHONE NUMBER
20. SUPERVISOR'S ORGANIZATION/DEPARTMENT
20a. SUPERVISOR'S E-MAIL ADDRESS
21. SIGNATURE OF INFORMATION OWNER/OPR
21a. PHONE NUMBER
21b. DATE (YYYYMMDD)
22. SIGNATURE OF IAO OR APPOINTEE
23. ORGANIZATION/DEPARTMENT
24. PHONE NUMBER
25. DATE
(YYYYMMDD)
DD FORM 2875, AUG 2009
PREVIOUS EDITION IS OBSOLETE.
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