SF 7643-DOE **U. S. DEPARTMENT OF ENERGY**

**NNSA SERVICE CENTER**

**CLEARANCE REQUEST/RECERTIFICATION/SUITABILITY FORM**

Instructions for Justification Form and Definitions

Check One:

**Applicant:** 1^st^ time clearance holder

**Incumbent:** Current clearance holder or previous clearance holder

Check One:

> **Contractor:** Already pre-checked, modify if need be. M&O or
> subcontractor employee. This applies to all SNL clearance requests and
> should always be checked.

**Federal:** DOE/NNSA Federal employee

**Requesting Site** -- anything is acceptable that clearly identifies
the site, for example -

SNL/CA, SNL/NM, Pantex, Oakland, Nevada, LANL, LLNL,

Y-12, Honeywell-KC, Honeywell-AL, WIPP,

Feds -- identify by site office: KCSO, LASO, NNSA-AL

**Clearance Number:** Add it if you know it, AB-000000, if not **[leave
blank]{.underline}** -- do not put N/A or unknown.

**Name, Date, Date of Birth, Place of Birth, Social Security #:** Self
Explanatory. MUST list complete name, no initials. For place of birth,
must list city and state.

**Citizenship** -- list country: USA, Iran, Germany, etc.

**Employer** (legal name): Examples -- Honeywell FM&T, University of
California. This is the actual company the individual works for. If the
individual is a sub-contractor, this is the contract company they work
for, not Sandia National Labs (ex: Ktech, SNL Consultant, ASAP, etc.).

**Employer Code/Facility Code:** Leave this blank, Personnel Security
Dept. (PSD) will fill in.

**Job Title** - Examples: Member of Technical Staff; Technician;
Consultant

**Subcontract Number** applies to sub-contractors to the M&O contractor
(ex: Ktech, Job Plus, ASAP, Consultants, etc.). Leave this blank for SNL
Employees.

**Human Reliability Program** (formerly PAP or PSAP)

**Direct Access/Protection of SNM**: Self-explanatory

**Nuclear Material Production Reactor Operator**: Self-explanatory

**Potential to Cause Unacceptable Damage** (Must be justified under
separate cover): This phrase formerly referred to PSAP/PAP positions.
Ignore for now while HRP merges the 2 programs. Can clarify at a later
date if need be.

**Sensitive Compartmental Information (SCI)**: Self-explanatory

**Type of Investigation:** DOE use only.

**Type of Clearance:** Check the appropriate clearance level: "L", "L/Q"
or "Q".

**Clearance Action:** Check the box that identifies the clearance action
required.

**"Q" & "L" Criteria Blocks**: Self-explanatory -- check off what
applies.

**Justification (narrative)**: [Intentionally]{.underline} kept at 3
lines -- keep it short/simple

1)  BRIEF description of duties

2)  Level of access -- this should match the criteria checked

3)  Frequency (daily, weekly, etc.)

**Clearance History**: Self-explanatory. If unknown, leave blank.

**Enclosure**: Leave blank, PSD use only.

**Certification:** Name/signature -- Self-explanatory Organization: Can
be Mail Stop, Group or whatever the site identifies with

> *Requesting official:* should always be submitted: Can be a SNL
> manager, team supervisor, or someone that has been given Delagation of
> Authority for a manager or team supervisor. **Always include a phone
> number, with area code.**
>
> *DOE Official or COTR:* Only applies to federals -- otherwise ignore
>
> *Contracting Security Official (M&O official):* PSD official

<table>
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<tbody>
<tr class="odd">
<td colspan="26"><p><strong>U. S. DEPARTMENT OF ENERGY</strong></p>
<p><strong>NNSA SERVICE CENTER</strong></p>
<p><strong>CLEARANCE REQUEST/RECERTIFICATION/SUITABILITY
FORM</strong></p></td>
</tr>
<tr class="even">
<td colspan="4"> Applicant Incumbent</td>
<td colspan="3"> Contractor Federal</td>
<td colspan="3"><p>Requesting Site</p>
<p>     </p></td>
<td colspan="7"><p>Clearance Number</p>
<p>     </p></td>
<td colspan="5"><p>Contract Number (M&amp;O)</p>
<p>DE-AC04-94AL85000</p></td>
<td colspan="4"><p>Date</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="16"><p>FULL Name (Last, First, Middle (no initial))</p>
<p>     </p></td>
<td colspan="4"><p>Date of Birth</p>
<p>     </p></td>
<td colspan="6"><p>Place of Birth (City and State)</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="5" rowspan="2"><p>Social Security Number</p>
<p>     </p></td>
<td colspan="4" rowspan="2"><p>Citizenship</p>
<p>     </p></td>
<td colspan="17">Employer (Legal Name)      </td>
</tr>
<tr class="odd">
<td colspan="5">PSD USE ONLY</td>
<td colspan="4">Employer Code:</td>
<td colspan="3">     </td>
<td colspan="3">Facility Code:</td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="15">Job Title:      </td>
<td colspan="11">Subcontract Number (if applicable):      </td>
</tr>
<tr class="odd">
<td colspan="15"> Human Reliability Program (formerly PAP or PSAP)</td>
<td colspan="11"> Sensitive Compartmented Information (SCI)</td>
</tr>
<tr class="even">
<td colspan="15"> Direct Access/Protection of SNM</td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="26"> Nuclear Material Production Reactor Operator</td>
</tr>
<tr class="even">
<td colspan="26"> Potential to Cause Unacceptable Damage (Must be
justified under separate cover)</td>
</tr>
<tr class="odd">
<td rowspan="2"><p><strong>DOE</strong></p>
<p><strong>USE</strong></p>
<p><strong>ONLY</strong></p></td>
<td colspan="25"></td>
</tr>
<tr class="even">
<td colspan="25">Type of Investigation:  SBI  BI  LBI  PRIS  NACLC
 NACC  FAC  FBC</td>
</tr>
<tr class="odd">
<td colspan="5"><strong>Type of Clearance:</strong></td>
<td colspan="3"> <strong>L</strong></td>
<td colspan="4"> <strong>L/Q</strong></td>
<td colspan="7"> <strong>Q</strong></td>
<td colspan="6"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"> Initial</td>
<td colspan="4"> Reinstate</td>
<td colspan="5"></td>
<td colspan="5"> Transfer</td>
<td colspan="3"> Upgrade</td>
<td colspan="6"> Reciprocity</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="5"> Reinvestigation</td>
<td colspan="5"> Extension</td>
<td colspan="3"> Downgrade</td>
<td colspan="6"> Suitability (DOE ONLY)</td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="5"> Special Update</td>
<td colspan="8"> Employer Code Change</td>
<td colspan="7"> Key Management Personnel</td>
</tr>
<tr class="odd">
<td colspan="12"><strong>"Q" CRITERIA</strong></td>
<td colspan="14"><strong>"L" CRITERIA</strong></td>
</tr>
<tr class="even">
<td colspan="12"> Top Secret Restricted Data</td>
<td colspan="14"> Secret National Security Information</td>
</tr>
<tr class="odd">
<td colspan="12"> Top Secret Formerly Restricted Data</td>
<td colspan="14"> Secret Formerly Restricted Data</td>
</tr>
<tr class="even">
<td colspan="12"> Top Secret National Security Information</td>
<td colspan="14"> Confidential Restricted Data</td>
</tr>
<tr class="odd">
<td colspan="12"> COMSEC Information</td>
<td colspan="14"> Confidential Formerly Restricted Data</td>
</tr>
<tr class="even">
<td colspan="12"> CRYPTO Information</td>
<td colspan="14"> Confidential National Security Information</td>
</tr>
<tr class="odd">
<td colspan="12"> Weapon Data Indicate Sigma(s) <u>     </u></td>
<td colspan="14"> Special Nuclear Material (Categories II &amp;
III)</td>
</tr>
<tr class="even">
<td colspan="12"> Secret Restricted Data</td>
<td colspan="14"> Continuous unescorted access to Classified (Limited
Security) Area</td>
</tr>
<tr class="odd">
<td colspan="12"> Special Nuclear Material (Category I)</td>
<td colspan="14"> Exclusion Area</td>
</tr>
<tr class="even">
<td colspan="12"> Exclusion Area Access</td>
<td colspan="14"></td>
</tr>
<tr class="odd">
<td colspan="26"><strong>JUSTIFICATION</strong></td>
</tr>
<tr class="even">
<td colspan="26"><p><em>Identify the specific job activity requiring a
clearance. Without revealing classified information describe –</em></p>
<p><em>(1) the duties of the position, (2) the level of classified
matter or SNM to be accessed, and (3) the frequency of
access.</em></p></td>
</tr>
<tr class="odd">
<td colspan="26"><ol type="1">
<li><p>Duties:      </p></li>
<li><p>Level:      </p></li>
<li><p>Frequency:      </p></li>
</ol></td>
</tr>
<tr class="even">
<td colspan="26"><strong>CLEARANCE HISTORY</strong></td>
</tr>
<tr class="odd">
<td colspan="15"> holds held a DOE clearance</td>
<td colspan="11">Level:      File #: <u>     </u></td>
</tr>
<tr class="even">
<td colspan="15"> holds held another agency clearance</td>
<td colspan="11">Level:     File #: <u>     </u></td>
</tr>
<tr class="odd">
<td colspan="15"> holds held Special Access</td>
<td colspan="11"> SCI PAP PSAP Other:<u>     </u></td>
</tr>
<tr class="even">
<td colspan="15"> Yes No Pre-employment check conducted</td>
<td colspan="11"> Yes No Investigation currently in progress</td>
</tr>
<tr class="odd">
<td colspan="26"><strong>ENCLOSURES – To be completed by
PSD</strong></td>
</tr>
<tr class="even">
<td colspan="13"> SF-86, "Questionnaire for Sensitive Position"</td>
<td colspan="13"> DOE F 5631.18, “Security Acknowledgement"</td>
</tr>
<tr class="odd">
<td colspan="13"> SF-171, Applicant for Federal Employment</td>
<td colspan="13"> DOE F 5631.29, "Security Termination Statement"</td>
</tr>
<tr class="even">
<td colspan="13"> F/P Cards (SF-87 Federal/FD 258: Contractors)</td>
<td colspan="13"> Other:      </td>
</tr>
<tr class="odd">
<td colspan="13"> DOE F 472.1, Fair Credit Report Act Release</td>
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="26"></td>
</tr>
<tr class="odd">
<td colspan="26"><strong>CERTIFICATION</strong></td>
</tr>
<tr class="even">
<td colspan="26">I certify that the DOE clearance that is being
requested/recertified is required in order for the subject to perform
official duties of the position described.</td>
</tr>
<tr class="odd">
<td colspan="13"><p>Requesting Official (Print Name):</p>
<p>     </p></td>
<td colspan="10" rowspan="2">Signature</td>
<td colspan="3" rowspan="2">Date      </td>
</tr>
<tr class="even">
<td colspan="6">Organization:      </td>
<td colspan="7">Phone No. (   )    -    </td>
</tr>
<tr class="odd">
<td colspan="13">DOE Official or Contracting Officer/Technical Rep
(COTR):</td>
<td colspan="10" rowspan="2">Signature</td>
<td colspan="3" rowspan="2">Date      </td>
</tr>
<tr class="even">
<td colspan="6">Organization:      </td>
<td colspan="7">Phone No. (   )    -    </td>
</tr>
<tr class="odd">
<td colspan="13">Contracting Security Official (M &amp; O
Official):</td>
<td colspan="10" rowspan="2">Signature</td>
<td colspan="3" rowspan="2">Date      </td>
</tr>
<tr class="even">
<td colspan="6">Organization:      </td>
<td colspan="7">Phone No. (   )    -    </td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="7"></td>
<td colspan="10"></td>
<td colspan="3"></td>
</tr>
</tbody>
</table>