+--------------------------------+----------+------+---+-------+---+-------+
| **U. S. DEPARTMENT OF ENERGY** | **SUB    |      |   | *     | * |       |
|                                | CONTRACT |      |   | *Effe | * |       |
| **NNSA SERVICE CENTER**        | N        |      |   | ctive | E |       |
|                                | UMBER:** |      |   | Da    | x |       |
| **HSPD-12 BADGE REQUEST FORM** |          |      |   | te:** | p |       |
|                                |          |      |   |       | i |       |
|                                |          |      |   | *     | r |       |
|                                |          |      |   | *\|** | a |       |
|                                |          |      |   |       | t |       |
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|                                |          |      |   |       | \ |       |
|                                |          |      |   |       | | |       |
|                                |          |      |   |       | * |       |
|                                |          |      |   |       | * |       |
|                                |          |      |   |       |   |       |
|                                |          |      |   |       |   |       |
|                                |          |      |   |       |   |       |
|                                |          |      |   |       |   |       |
|                                |          |      |   |       |   |       |
+--------------------------------+----------+------+---+-------+---+-------+
|                                | *        |      | * |       |   |       |
|                                | *BADGE** |      | * |       |   |       |
|                                |          |      | B |       |   |       |
|                                | **E      |      | A |       |   |       |
|                                | FFECTIVE |      | D |       |   |       |
|                                | DATE:**  |      | G |       |   |       |
|                                |          |      | E |       |   |       |
|                                |          |      | * |       |   |       |
|                                |          |      | * |       |   |       |
|                                |          |      |   |       |   |       |
|                                |          |      | * |       |   |       |
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|                                |          |      | I |       |   |       |
|                                |          |      | R |       |   |       |
|                                |          |      | A |       |   |       |
|                                |          |      | T |       |   |       |
|                                |          |      | I |       |   |       |
|                                |          |      | O |       |   |       |
|                                |          |      | N |       |   |       |
|                                |          |      | D |       |   |       |
|                                |          |      | A |       |   |       |
|                                |          |      | T |       |   |       |
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|                                |          |      | : |       |   |       |
|                                |          |      | * |       |   |       |
|                                |          |      | * |       |   |       |
+--------------------------------+----------+------+---+-------+---+-------+
|                                | (*       |      |   |       |   |       |
|                                | *Badge** |      |   |       |   |       |
|                                | **e      |      |   |       |   |       |
|                                | ffective |      |   |       |   |       |
|                                | date**   |      |   |       |   |       |
|                                | should   |      |   |       |   |       |
|                                | coincide |      |   |       |   |       |
|                                | with     |      |   |       |   |       |
|                                | [date    |      |   |       |   |       |
|                                | employee |      |   |       |   |       |
|                                | **will   |      |   |       |   |       |
|                                | require  |      |   |       |   |       |
|                                | Y-12     |      |   |       |   |       |
|                                | access   |      |   |       |   |       |
|                                | **]{.und |      |   |       |   |       |
|                                | erline}. |      |   |       |   |       |
|                                | **Badge  |      |   |       |   |       |
|                                | ex       |      |   |       |   |       |
|                                | piration |      |   |       |   |       |
|                                | date**   |      |   |       |   |       |
|                                | should   |      |   |       |   |       |
|                                | coincide |      |   |       |   |       |
|                                | with     |      |   |       |   |       |
|                                | [date    |      |   |       |   |       |
|                                | employee |      |   |       |   |       |
|                                | **will   |      |   |       |   |       |
|                                | no       |      |   |       |   |       |
|                                | longer   |      |   |       |   |       |
|                                | r        |      |   |       |   |       |
|                                | equire** |      |   |       |   |       |
|                                | access   |      |   |       |   |       |
|                                | for work |      |   |       |   |       |
|                                | under    |      |   |       |   |       |
|                                | s        |      |   |       |   |       |
|                                | ubcontra |      |   |       |   |       |
|                                | ct]{.und |      |   |       |   |       |
|                                | erline}) |      |   |       |   |       |
+--------------------------------+----------+------+---+-------+---+-------+

<table>
<colgroup>
<col style="width: 14%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 9%" />
<col style="width: 18%" />
<col style="width: 14%" />
</colgroup>
<tbody>
<tr class="odd">
<td><p> <strong>Contractor</strong></p>
<p> <strong>Federal</strong></p></td>
<td colspan="3"><p><strong>Requesting Site</strong></p>
<p>     </p></td>
<td colspan="5"><p><strong>Contract Number Or Agreement</strong></p>
<p>     </p></td>
<td colspan="2"><p><strong>Employer (Legal Name)</strong></p>
<p>     </p></td>
<td><p><strong>Sec. Brief. Date:</strong></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="5"><strong>Name (Last, First, Middle)</strong></td>
<td colspan="5"><strong>Date of Birth</strong></td>
<td colspan="2"><strong>Place of Birth</strong></td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2"><strong>Social Security Number</strong></td>
<td colspan="4"><strong>Citizenship</strong></td>
<td colspan="6"><strong>Applicant’s Address (and e-mail
address)</strong></td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="6"><strong>Applicants Position</strong></td>
<td colspan="6"><strong>Applicants Contact Information (Day &amp;
Evening Phone Numbers)</strong></td>
</tr>
<tr class="odd">
<td colspan="6">     </td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="12"><blockquote>
<p><strong>Clearance Required?</strong> <strong>Yes</strong>
<strong>No</strong> <strong><u>HSPD-12 DATA &amp; Clearance
Information</u></strong></p>
</blockquote>
<p> holds held Has never had an HSPD-12 Badge</p>
<p> holds held Has never had a DOE/NNSA clearance
<strong>Level:</strong> <strong>L</strong> <strong>L/Q</strong>
<strong>Q Date:</strong> From <u>     </u> to <u>     </u></p>
<p> holds held Has never had another agencies clearance
<strong>Level:</strong> <u>     </u> <strong>Date:</strong> From
<u>     </u> to <u>     </u></p>
<p> Investigation currently in progress for clearance
<strong>Agency:</strong> <u>     </u> <strong>Level:</strong>
<u>     </u></p>
<p> Federal Only: Has had an investigation conducted as part of
employment? <strong>Yes</strong> <strong>No</strong>
<strong>Agency:</strong> <u>     </u> <strong>Type:</strong>
<u>     </u></p></td>
</tr>
<tr class="odd">
<td colspan="12"><strong><u>Purpose</u></strong></td>
</tr>
<tr class="even">
<td colspan="12"><em>The purpose of this data collection is in
accordance with <strong>DOE N 206.3</strong> regarding identity-proofing
procedures.</em></td>
</tr>
<tr class="odd">
<td colspan="12"><strong><em>For use by Personnel Security Only</em>
ENCLOSURES</strong></td>
</tr>
<tr class="even">
<td colspan="7"><p> SF-86, Documents for HSPD-12 (not entire clearance
packet ie. Security Acknowledgement &amp; Clearance Justification)</p>
<p><strong>1 copy with original signature</strong></p></td>
<td colspan="5"><p> <u>Copy Identification Documents</u></p>
<p> <u>DOE F 472.1</u>, <em>Fair Credit Report Act Release</em>
<strong>1 original copy</strong></p></td>
</tr>
<tr class="odd">
<td colspan="7"><p> <u>F/P Cards</u> (SF-87 Federal/FD 258:
Contractors)</p>
<p><strong>1 original for HSPD-12 Identity Proofing
File</strong></p></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="7"> Other:      </td>
<td colspan="5"> Other:      </td>
</tr>
<tr class="odd">
<td colspan="12"><strong>CERTIFICATION</strong></td>
</tr>
<tr class="even">
<td colspan="12">I certify that the HSPD-12 Badge is being
requested/certified in accordance with the <strong>DOE N
206.3.</strong></td>
</tr>
<tr class="odd">
<td colspan="8"><strong>Applicant (Print Name)</strong> <em>(Applicant
will sign when receiving badge)</em></td>
<td colspan="3" rowspan="2"><strong>Signature</strong></td>
<td rowspan="2"><p><strong>Date</strong></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3">     </td>
<td colspan="5">Phone No. (   )    -    </td>
</tr>
<tr class="odd">
<td colspan="8"><p><strong>Sponsor Name/Badge#/Employer Requesting
Official (Print Name):</strong></p>
<p>     </p></td>
<td colspan="3" rowspan="2"><strong>Signature</strong></td>
<td rowspan="2"><p><strong>Date</strong></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3"><p>Organization/Address:</p>
<p>     </p></td>
<td colspan="5">Phone No. (   )    -    </td>
</tr>
<tr class="odd">
<td colspan="8"><p><strong>Contract Representative/Issuer:</strong></p>
<p>     </p></td>
<td colspan="3" rowspan="2"><strong>Signature</strong></td>
<td rowspan="2"><p><strong>Date</strong></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3"><p>Organization:</p>
<p>     </p></td>
<td colspan="5">Phone No. (   )    -    </td>
</tr>
<tr class="odd">
<td colspan="8"><p><strong>NNSA Site Office Federal Official or
<u>Delegated Registrar</u>:</strong></p>
<p>     </p></td>
<td colspan="3" rowspan="2"><strong>Signature</strong></td>
<td rowspan="2"><p><strong>Date</strong></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3"><p>Organization:</p>
<p>     </p></td>
<td colspan="5">Phone No. (   )    -    </td>
</tr>
<tr class="odd">
<td colspan="8"><p><strong>NNSA SC PSD Receipt:</strong></p>
<p>     </p></td>
<td colspan="3" rowspan="2"><strong>Signature</strong></td>
<td rowspan="2"><p><strong>Date</strong></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3"><p>Print Name:</p>
<p>     </p></td>
<td colspan="5">Phone No. (   )    -    </td>
</tr>
</tbody>
</table>

**Sponsor: Fax completed form to Y-12 Badging Office @ 574-7200**