Security Check In

Rank: _____________ Full Name: ___________________________________Service/Company: __________________

 (Last, First MI) 

SSN/DoD EDI PN ________________________________ Position/FMTS#____________________________________

Separation/End of Tour Date: _______________________ Directorate: ______________Phone: ___________________ 

Supervisor's Name: _________________________ ______Supervisor's Phone: _________________________________ 

Active Duty NG Reserve IMA Reserve TPU Reserve AGR US Gov CIV CONTR 

Are you a dual citizen? YES / NO

Are you married? YES / NO

Do you hold a foreign passport? YES / NO 

Citizenship of spouse: _________________ 

I understand that prior to entering into any marriage or cohabitation with a foreign national, I will declare my intent in 

writing to the SSO. 

I have read and understand these requirements _____________ (Please Initial)

1. List any other name/aliases used: _______________________________

2. Had a 2 year or more break in service? YES / NO

3. Since your last security clearance investigation have any of the following occurred:

a. Been Married/Divorced? YES / NO

If Yes, has your adjudicating service been notified?

b. Acquired any foreign relationships? YES / NO

If Yes, has your adjudicating service been notified? 

c. Been detained, held, arrested, indicted or summoned into court (civilian or military), or convicted,

fined, or been ordered to post bail or collateral for violating a law, police regulation or ordinance

excluding minor traffic violations of less than $300, unless alcohol or drug related)? YES / NO 

d. Had trouble meeting financial obligation, filed for bankruptcy, Chapter 13, or had am account 

placed in collection? YES / NO

If you have answered YES to any of the above questions, further information is required. Please 

explain, in detail on a separate sheet of paper. 

___________________________

 Date

__________________________________________

Signature 

I certify that the entries made by me above are true, complete and correct to the best of my 

knowledge and are made in good faith. I understand that a knowing and willful false statement 

on the form can result in punishment by fine, imprisonment or both. (U.S. Code Title 18)
Maintaining Security Clearance Requirements

Reportable Items

Please read the required items that must be reported to the Special Security Branch (SSB), and sign the 

acknowledgement below. 

Change in Personal Status

• Marriage, Divorce or Cohabitation

• Intent to marry a Foreign National

• Official name changes

Financial Hardship or Financial Gain

• Bankruptcy or Credit Judgments

• Short Sales, Foreclosures or Tax Liens

• Excessive Debt or Inability to pay bills/debt

• Repossessions or wage garnishments

Unlawful Activities

• All Arrests and adverse involvement with law enforcement

• DUI/DWI, and any tickets or citation in which Alcohol or Drugs were involved

• Any ticket or citations in excess of $300.00

Outside Activities

Service to any foreign nation; representative of any foreign interest; or with foreign, domestic, or 

international organization or person, engaged in intelligence work. 

Foreign Travel 

• Both official and unofficial travel must be reported prior to traveling and a Post Travel

Questionnaire must be completed upon return

• Report any unusual incidents that occurred during travel, as well as any foreign contacts

Foreign Contacts 

• Contacts in which unauthorized access is sought to classified or sensitive information/technology

• Contacts with known or suspected intelligence officers from any country.

• Contact with, or invitations from, foreign government officials.

• Contacts that are of a close and continuous personal association.

• Contact via social media (e.g Facebook friends) must be reported.

Personnel whose duties require official contact with foreign government or nationals are exempt from 

reporting contacts directly associated with their duties, unless an incident occurs or the relationship 

extends outside of the official duties.

My signature certifies that I understand and will meet the requirements outlined.

_________________________ _________________________ 

Signature Date 
Employee Outside Activities

Please read the below excerpt from DoDM 5105.21-V3, SCI Administrative Security Manual, 

and sign the acknowledgement. 

1. Potential conflicts with an individual’s responsibility to protect SCI material may arise from 

outside employment or other outside activity to include contact or association with foreign 

nationals. In cases where such employment or association has resulted in a suspected or 

established compromise of SCI, the local SCI security official and supporting CI activity must be 

advised immediately. Involvement in non-U.S. Government employment or activities that raise 

potential conflicts with an individual’s responsibility to protect SCI information is of security 

concern and must be reviewed by an SCI security official to determine whether the conflict is of 

such a nature that the individual’s SCI access should be reevaluated.

2. Individuals who have or are being considered for SCI access must report in writing to the local 

SCI security official any existing or contemplated outside employment or activity that meets the 

two criteria below. In addition, an initial or updated SF 86 must include details of such outside 

employment or activities.

a. The employment includes compensated or volunteer service with any foreign nation; with 

a representative of any foreign interest; or with any foreign, domestic, or international 

organization or person engaged in analysis, discussion, or publication of material on 

intelligence, defense, or foreign affairs.

b. The employment or activity raises doubt as to an individual’s willingness or ability to 

safeguard SCI information. In this circumstance, the servicing SSO shall advise the 

individual that continuing such employment or activity may result in withdrawal of SCI 

access and shall provide the individual an opportunity to discontinue such employment or 

activity. If the individual terminates the employment or activity of security concern, the 

individual’s SCI access approval(s) may be continued provided this is otherwise 

consistent with national security requirements.

3. The provisions of this section of this enclosure (paragraphs 13.a. and 13.b., in their entirety) shall 

be made available to individuals for reading during SCI indoctrination. Annual security 

education for SCI-indoctrinated individuals shall advise them:

a. To report in writing to their local SCI security officer any existing or contemplated 

outside employment or activity that appears to meet the above criteria.

b. That the written report must be submitted before accepting the outside employment or 

activity.

My signature certifies that I understand the statements made, and will follow the guidelines outlined.

_________________________ _________________________

Signature Date
Conflict of Interest

Security Education Briefing

1. All personnel granted access to Sensitive Compartmented Information (SCI) are legally 

bound to protect and safeguard the information under the guidelines set forth by the 

Nondisclosure Statement (NdS).

2. Reserve military members are authorized to use their SCI access only when they are under 

official military orders and a valid “need to know” exists. All information protected through 

the various SCI programs can be used only to support and assist the operational endeavors of 

the Department of Defense, not the individual or the civilian firm. All personnel must be 

aware of this delicate balance. Any disregard of these procedures could potentially cause 

serious security problems to arise or undue embarrassment to the Department. The individual 

is legally bound by the obligation set forth in the NdS.

3. A few simple precautionary measures can prevent a conflict of interest. The SCI security 

badge is to be used only when on official military orders. The SCI security badge should be 

maintained by the administrative office that supports each individual’s reserve duties. If there 

are problems identifying the support personnel, each individual must contact the SSO. Next, 

verify through the SSO the proper level of SCI accesses. SCI accesses obtained through 

civilian employment or external Government agencies shall not suffice. All DoD SCI 

accesses must be authorized and approved through the proper cognizant authority.

4. In summary, any information gained while in an indoctrinated status can be used only in 

support of military issues. The transfer of SCI from one agency to another, either verbally or 

by documentation, can only be accomplished through proper security channels. If ever in 

doubt as to the proper security procedures, contact your local Special Security Office for 

advice.

My signature certifies that I understand the statements made, and will follow the guidelines outlined.

_________________________ _________________________

Last Name, First MI SSN

_________________________ _________________________

Signature Date

_________________________ _________________________

Signature of Witness Date
Attestation to Understanding Responsibilities

For Protection of Classified Information

Please read the below statement and sign the acknowledgement below affirming your 

understanding and willingness to protect classified information.

“I accept the responsibilities associated with being granted access to classified national security 

information. I am aware of my obligation to protect classified national security information 

through proper safeguarding and limiting access to individuals with the proper security 

clearance, accesses and official need-to-know. I further understand that in being granted access 

to classified information and/or Special Access Programs/Sensitive Compartmented Information 

a special confidence and trust has been places in me by the United States Government”

My signature certifies that I understand the statement above and will follow the requirements associated 

with access to classified information.

_________________________ _________________________

Last Name, First MI SSN

_________________________ _________________________

Signature Date

_________________________ _________________________

Signature of Witness Date