**U. S. DEPARTMENT OF ENERGY**

**NNSA SERVICE CENTER**

**     **

**Homeland Security Presidential Directive (HSPD-12)**

**BADGE REQUEST FORM**

**INSTRUCTIONS**

**Do you need this form?**

**This form is required for all individuals being requested for an
initial DOE Standard badge and Security Clearance and must be
accompanied by the following forms depending on your status:**

a.  **SNL Employees (to include student interns) -- Clearance
    Request/Recertification/Suitability Form (DOE F 472.1C).**

b.  **Contractors and Consultants -- Contractor/Consultant
    Badge/Clearance Request Form (SF 7643-CEC) and Clearance
    Request/Recertification/Suitability Form (DOE F 472.1C).**

Section 1 -- **Applicant Information**

a.  Check the appropriate box -- modify if needed. "Contractor" is
    pre-checked for all SNL requests since we are an M&O Contractor to
    DOE.

b.  Enter the requesting site where the applicant will be badged out of
    (ex.: SNL/NM, SNL/CA, SNL/TTR).

c.  This box is pre-filled with the contract number, do not change this.

d.  Enter the employer's legal name. For contractors, this is the
    company they are obtaining a badge under. For Sandia Employees, this
    should reflect Sandia National Laboratories.

e.  Enter the date of the request.

f.  Enter FULL name of applicant to include full middle name, no
    initial. If no middle name, enter "NMN". Make sure you enter it as
    requested -- Last, First, Middle.

g.  Enter the applicant's date of birth (mm/dd/yyyy).

h.  Enter the applicant's place of birth (city and state).

i.  Enter the applicant's SSN.

j.  Enter the citizenship of the applicant.

k.  Enter the applicant's address to include city, state and ZIP code.

l.  Enter the applicant's position title.

m.  Enter any additional contact information for the applicant (Phone #,
    e-mail address, etc.)

Section 2 -- **HSPD-12 Data & Clearance Information**

-   Fill in as much information as you know. If unknown, leave blank.

Section 3 -- **Enclosures**

-   This will be filled in by the Personnel Security Department (PSD).

Section 4 -- **Certification**

-   *Applicant* -- the applicant must sign and date here.

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-   *Sponsor/Employer Requesting Official* -- the Sponsoring Manager,
    team leader, or individual with delegation of authority for a manger
    or team leader must sign and date here. For contractors -- the
    Facility Security Officer (FSO) may also sign in this box.

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-   *Contract Representative* -- this is to be signed by Personnel
    Security Dept.

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-   *NNSA Site Office* -- this will be completed by DOE.

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-   *NNSA SC PSD Receipt* -- this will be completed by DOE.

**U. S. DEPARTMENT OF ENERGY**

**NNSA SERVICE CENTER**

HSPD-12 BADGE REQUEST FORM

<table>
<colgroup>
<col style="width: 15%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 15%" />
<col style="width: 14%" />
<col style="width: 1%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="13"><strong><u>Section 1.</u> <u>Applicant
Information</u></strong></td>
</tr>
<tr class="even">
<td><p>a. Contractor</p>
<p> Federal</p></td>
<td colspan="3"><p>b. Requesting Site</p>
<p>     </p></td>
<td colspan="5"><p>c. Contract Number/Agreement</p>
<p>DE-AC04-94AL85000</p></td>
<td colspan="3"><p>d. Employer (Legal Name)</p>
<p>     </p></td>
<td><p>e. Date:</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="7">f. Name (Last, First, Middle (no initial))</td>
<td colspan="3">g. Date of Birth</td>
<td colspan="3">h. Place of Birth (city and state)</td>
</tr>
<tr class="even">
<td colspan="7">     </td>
<td colspan="3">     </td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="2">i. Social Security Number</td>
<td colspan="3">j. Citizenship</td>
<td colspan="8">k. Applicant’s Address</td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="8">     </td>
</tr>
<tr class="odd">
<td colspan="5">l. Applicants Position</td>
<td colspan="8">m. Applicants Contact Information</td>
</tr>
<tr class="even">
<td colspan="5">     </td>
<td colspan="8">     </td>
</tr>
<tr class="odd">
<td colspan="13"><strong><u>Section 2.</u> <u>HSPD-12 Data &amp;
Clearance Information</u></strong></td>
</tr>
<tr class="even">
<td colspan="13"><p> holds held Has never had an HSPD-12 Badge</p>
<p> holds held Has never had a DOE/NNSA clearance Level: L L/Q Q
<strong><u>Date</u></strong>: From       to      </p>
<p> holds held Has never had another agencies clearance Level:      
<strong><u>Date</u></strong>: From       to      </p>
<p> Investigation currently in progress for clearance Agency:      
Level:      </p>
<p> Federal Only: Has had an investigation conducted as part of
employment? Yes No Agency:       Type:      </p></td>
</tr>
<tr class="odd">
<td colspan="13"><strong><u>Purpose</u></strong></td>
</tr>
<tr class="even">
<td colspan="13"><em>The purpose of this data collection is in
accordance with DOE N 206.3 regarding identity-proofing
procedures.</em></td>
</tr>
<tr class="odd">
<td colspan="13"><strong><u>Section 3.</u> <u>Enclosures – To be
completed by Personnel Security Department</u></strong></td>
</tr>
<tr class="even">
<td colspan="6"><p> SF-86, Documents for HSPD-12 (not entire clearance
packet ie. Security Acknowledgement &amp; Clearance Justification)</p>
<p>1 original signature</p></td>
<td colspan="7"> Copy Identification Documents</td>
</tr>
<tr class="odd">
<td colspan="6"><p> F/P Cards (SF-87 Federal/FD 258: Contractors)</p>
<p>1 for HSPD-12 Identity Proofing File</p></td>
<td colspan="7"> DOE F 472.1, Fair Credit Report Act Release- 1
original</td>
</tr>
<tr class="even">
<td colspan="6"> Other:      </td>
<td colspan="7"> Other:      </td>
</tr>
<tr class="odd">
<td colspan="13"><strong><u>Section 4.</u>
<u>Certification</u></strong></td>
</tr>
<tr class="even">
<td colspan="13">I certify that the HSPD-12 Badge is being
requested/certified in accordance with the DOE N 206.3.</td>
</tr>
<tr class="odd">
<td colspan="8"><p>Applicant (Print Name):</p>
<p>     </p></td>
<td colspan="3" rowspan="2">Signature</td>
<td colspan="2" rowspan="2"><p>Date</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>Sponsor/Employer Requesting Official (Print
Name):</p>
<p>     </p></td>
<td colspan="3" rowspan="2">Signature</td>
<td colspan="2" rowspan="2"><p>Date</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3">Organization:      </td>
<td colspan="5">Phone No. (   )    -    </td>
</tr>
<tr class="odd">
<td colspan="8"><p>Contract Representative:</p>
<p>     </p></td>
<td colspan="3" rowspan="2">Signature</td>
<td colspan="2" rowspan="2"><p>Date</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3">Organization:      </td>
<td colspan="5">Phone No. (   )    -    </td>
</tr>
<tr class="odd">
<td colspan="8"><p>NNSA Site Office Federal Official or Delegate:</p>
<p>     </p></td>
<td colspan="3" rowspan="2">Signature</td>
<td colspan="2" rowspan="2"><p>Date</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3">Organization:      </td>
<td colspan="5">Phone No. (   )    -    </td>
</tr>
<tr class="odd">
<td colspan="8"><p>NNSA SC PSD Receipt (Print Name):</p>
<p>     </p></td>
<td colspan="3" rowspan="2">Signature</td>
<td colspan="2" rowspan="2"><p>Date</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="5">Phone No. (   )    -    </td>
</tr>
</tbody>
</table>