NRC FORM 176

(11-07-2022)

NRC MD 12.3

U.S. NUCLEAR REGULATORY COMMISSION 

A. SECURITY ACKNOWLEDGMENT

APPROVED BY OMB: NO. 3150-0239 EXPIRES: 11/30/2025

Estimated burden per response to comply with this mandatory information collection request: 12 minutes. 

This submittal is used by NRC to initiate termination of access authorization. Send comments regarding 

burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear 

Regulatory Commission, Washington, DC 20555-0001, or by email to Infocollects.Resource@nrc.gov, and 

the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0239), Attn: Desk Officer 

for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; email: 

oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person is not required to 

respond to, a collection of information unless the document requesting or requiring the collection displays a 

currently valid OMB control number.

INSTRUCTIONS: Applicants for U.S. Nuclear Regulatory Commission (NRC) Access Authorization (Security Clearance), 

 Complete Section A. and C. 

 Applicants for Special Nuclear Material Access Authorization (employees of licensed organizations or other 

 individuals affected by 10 CFR Part 11). Complete Section B. and C.

I , , in anticipation of my access authorization by the United States Nuclear Regulatory

Commission (NRC), make the following statement with the understanding and intent that my statement will be used by the NRC in carrying 

out its obligation to protect the security of Restricted Data and Controlled Unclassified Information.

1. I understand that it is the policy of the NRC to control the dissemination of Restricted Data, and Controlled Unclassified Information 

 (e.g., privacy information, Safeguards Information, and proprietary information) in such a manner as to assure the common defense 

 and security.

2. I understand that, in carrying out this policy, the NRC has issued and will issue and revise, as circumstances require, certain 

 instructions and regulations pertaining to the control and dissemination of Restricted Data, and Controlled Unclassified information.

3. I shall not unlawfully reveal to any person any Restricted Data, or Controlled Unclassified Information, of which I may gain knowledge 

 as a result of my employment assignment, or duties, except as authorized by law, regulations of the NRC, or in writing by officials of 

 the NRC empowered to grant permission for such disclosure.

4. I am aware that the Atomic Energy Act of 1954, as amended, U.S. Code, Title 18, "Crimes and Criminal Procedures," and 32 Code of 

 Federal Regulations, Part 2002, "Controlled Unclassified Information” prescribe penalties for unauthorized disclosure of Restricted 

 Data, Formerly Restricted Data, Controlled Unclassified Information, and other information relating to the national defense, and for 

 loss, destruction or compromise of such information through gross negligence.

5. I am aware that, unless and until I am released in writing by an authorized representative of the U.S. Government, all conditions and 

 obligations imposed upon me by virtue of my having executed SF 189, “Classified Information Nondisclosure Agreement,” or SF 312 

 of the same title, remain in full force and effect.

6. I am aware that I may be liable for damages if I reveal to any unauthorized person Controlled Unclassified information (e.g., privacy 

 information, proprietary information) of which I have gained Knowledge as a result of my employment, affiliation with NRC.

7. I understand that revealing or disclosing Restricted Data or Controlled Unclassified Information, to any unauthorized personnel 

 constitute sufficient cause for termination or my association with the NRC. 

8. I understand that the NRC desires to be informed when persons granted NRC security clearance propose to travel outside of the 

 United States and its territories NRC wishes to be advised of such travel in order to inform the individual of the possible risks to 

 personal safety in view of the classified information known to the individual. Informing the NRC of travel outside of the United States 

 and its territories does not apply to individuals who obtain an NRC security clearance and receive access to NRC classified information 

 solely as employees of other Government agencies or their contractors.

9. I am aware that I may be subject to criminal penalties if I make any statement of material facts on my personnel security forms or 

 related information in application for my NRC security clearance knowing that such statement is false or if I willfully conceal any 

 material fact (Title 18, U.S. Code, Section 1001).

10. I understand that I am to comply with all reporting requirements. I agree to notify the NRC, Division of Facilities and Security, within 5 

 days of reportable information as set forth in Security Executive Agent Directive (SEAD 3) or other applicable guidance, including but 

 not limited to, arrests, charges (INCLUDING CHARGES THAT ARE DISMISSED) or detentions by Federal State or other law 

 enforcement authorities, for any violation of any Federal, military, State, county or municipal law, regulation or ordinance other than 

 minor traffic violations for which a fine of $150 or less was imposed, occurring during any period in which I may hold NRC security 

 clearance or which occurred subsequent to the completion of Standard Form 86, "Questionnaire for National Security Positions," or 

 Standard Form 86C, "The Standard Form 86 Certification." 

City and State where Signed Name of Employer

Date

NRC FORM 176 (11-07-2022) Page 1

Social Security Number (Last 4 digits) Signature

*Note: Social Security Numbers must not be visible on the outside of any package sent by mail.
NRC FORM 176

(11-07-2022)

NRC MD 12.3

U.S. NUCLEAR REGULATORY COMMISSION 

B. SPECIAL NUCLEAR MATERIAL ACCESS AUTHORIZATION ACKNOWLEDGMENT 

NRC FORM 176 (11-07-2022) Page 2

I , , in anticipation of my special nuclear material access authorization ("U" or "R") by

the United States Nuclear Regulatory Commission (NRC), make the following statement with the understanding and intent that my 

statement will be used by the NRC in carrying out its obligation to assure the control and safeguarding of special nuclear material in 

accordance with the terms of the Atomic Energy Act of 1954, as amended. I understand that:

1. It is the policy of the NRC to regulate access to, and provide for control over, special nuclear material in such a manner as to provide 

 high assurance that activities involving such materials are not inimical to the common defense and security and do not constitute an 

 unreasonable risk to the public health and safety.

2. I understand, that in carrying out this policy, the NRC has issued, and will issue and revise as circumstances require, certain 

 instructions and regulations pertaining to access to and control of special nuclear material.

3. Any theft or other unlawful diversion of special nuclear material, or any attempt or conspiracy to steal, or unlawfully divert such 

 material, is a criminal violation of the Atomic Energy Act of 1954, as amended, and subject to criminal penalties.

5. I understand that I am to notify the NRC, Division of Facilities and Security, within 5 days of all arrests, charges (INCLUDING 

 CHARGES THAT ARE DISMISSED) or detentions by Federal, State or other law enforcement authorities, for any violation of any 

 Federal, military, State, county or municipal law, regulation or ordinance other than minor traffic violations for which a fine of $150 or 

 less was imposed, occurring during any period in which I may hold an NRC special nuclear material access authorization or which 

 occurred subsequent to the completion of Standard Form 86, "Questionnaire for National Security Positions," or Standard Form 86C, 

 "The Standard Form 86 Certification."

City and State Where Signed Name of Employer

Date Social Security Number (Last 4 digits) Signature

4. I am prohibited from providing direct or indirect assistance in the development or production of special nuclear material outside of the 

 United States, to include technology transfers and assistance related to certain nuclear fuel-cycle activities, commercial nuclear power 

 plants, and research and test reactors, unless authorized by the Secretary of Energy and/or the U.S. Nuclear Regulatory Commission 

 in accordance with the requirements of Atomic Energy Act of 1954, as amended, and 10 CFR Part 810. I understand that this 

 prohibition is on-going and applies to my activities and employment upon leaving the NRC, and includes transfer of physical 

 documents, electronic media or transfers, and/or knowledge and expertise. Violation of this prohibition could subject me to criminal 

 penalties.
NRC FORM 176

(11-07-2022)

NRC MD 12.3

U.S. NUCLEAR REGULATORY COMMISSION 

C. SECURITY DEBRIEFING ACKNOWLEDGEMENT

 I reaffirm that the provisions of the espionage laws, other federal criminal laws and executive orders 

 applicable to the safeguarding of classified information, Restricted Data, National Security Information, 

 or Controlled Unclassified Information, have been made available to me; I have returned or 

 destroyed, in accordance with NRC security regulations, all classified and/or sensitive information which 

 I may have had in my custody; I will not communicate or transmit classified information to any 

 unauthorized person or organization; I will promptly report to the Federal Bureau of Investigation 

 any attempt by an unauthorized person to solicit classified information, and 

I Have Received A Security Debriefing. I Have Not Received A Security Debriefing.

Typed or Printed Name of Witness

Signature and Date - Employee

Signature and Date - Witness

Social Security Number (Last 4 digits)

NRC FORM 176 (11-07-2022) Page 3

Typed or Printed Name of Employee
PRIVACY ACT STATEMENT 

SECURITY ACKNOWLEDGMENT/SPECIAL NUCLEAR MATERIAL ACCESS AUTHORIZATION 

ACKNOWLEDGMENT 

NRC FORM 176

Pursuant to 5 U.S.C. 552(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), 

the following statement is furnished to individuals who supply information to the Nuclear Regulatory 

Commission (NRC) on NRC Form 176. This information is maintained in a system of records designated as 

NRC-39 and described at 84 Federal Register 71568 (December 27, 2019), or the most recent Federal 

Register publication of the NRC's "Republication of Systems of Records Notices" that is located in NRC's 

Agencywide Documents Access and Management System (ADAMS).

1. AUTHORITY: 42 U.S.C. 2011 et seq.; 42 U.S.C. 2165, 2201(i), 2201a, and 2284; 42 U.S.C. 5801 et seq.; 

Executive Order (E.O.) 9397, as amended by E.O. 13478; E.O. 10450, as amended; E.O. 10865, as amended; 

E.O. 13467, E.O. 13526; E.O. 13587;10 CFR Parts 10, 11, 14, 25, 50, 73, 95; OMB Circular No. A-130; 

Revised; 5 CFR 731, 732, and authorities cited therein.

2. PRINCIPAL PURPOSE(S): To determine your initial or continuing eligibility for NRC access to Restricted 

Data, National Security Information and other classified information, and unclassified Safeguards Information; 

or for access to or control over special nuclear material.

3. ROUTINE USE(S): Information in these records may be used by the Division of Facilities and Security and 

on a need-to-know basis by appropriate NRC officials, Hearing Examiners, Personnel Security Review Panel 

members, Office of Personnel Management, Central Intelligence Agency, and other Federal agencies to 

determine clearance or access authorization eligibility; to determine eligibility for access to NRC buildings or 

access to Federal automated information systems or data; to certify clearance or access authorization; to 

maintain the NRC personnel security program; and to provide licensees information needed for unescorted 

access or access to safeguard information determinations. Information may be disclosed in accordance with 

any of the Routine Uses listed in the Prefatory Statement of General Routine Uses, including to an appropriate 

Federal, State, local or Foreign agency in the event the information indicates a violation or potential violation of 

law; in the course of an administrative or judicial proceeding; to an appropriate Federal, State, local and foreign 

agency to the extent relevant and necessary for an NRC decision about you or to the extent relevant and 

necessary for that agency's decision about you; in the course of discovery under a protective order issued by a 

court of competent jurisdiction, and in presenting evidence; to a Congressional office to respond to their inquiry 

made at your request; to NRC-paid experts, consultants, and others under contract with the NRC, on a needto-know basis; or to appropriate persons and entities for purposes of response and remedial efforts in the 

event of a suspected or confirmed breach of data from this system of records.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT 

PROVIDING INFORMATION: Disclosure of this information is voluntary; however, if it is not supplied, your 

access authorization may be delayed or denied.

5. SYSTEM MANAGER(S) AND ADDRESS: Director, Division of Facilities and Security, Office of 

Administration, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.