Form DHS Form 9014 DHS Form 9014 CI/KR Sector Clearance Program Request

DEPARTMENT OF HOMELAND SECURITY

CIKR Sector Clearance Program Request

OMB No. 1670-####
Expiration Date: MM/DD/YYYY

**Please complete the form with the exception of your SSN, Date of Birth, and Place of Birth. You will be contacted directly by a DHS
Security Specialist for this information.
FULL NAME:
DATE:

COMPANY NAME/ADDRESS:

SECTOR:

DEGREE OF

RECIPROCITY/REINSTATEMENT?

YES

CLEARANCE:

NO

SECRET
PHONE:

EMAIL ADDRESS:

BACKGROUND INFORMATION
DATE OF BIRTH:

PLACE OF BIRTH:

SOCIAL SECURITY NUMBER:

U.S. CITIZEN:

YES

NO

JUSTIFICATION:

. Subjects responsibilities

Subject serves as
(Position within company)

include
.
Subject's association memberships include
.
Subject's positions require coordination with the Department of Homeland Security and the sharing of classified
information regarding threats to and protection of the nation's critical infrastructure involving the
Sector.
*Provide the following information if you previously held or currently hold a clearance*
Subject
previously held
currently holds a
Secret
Top Secret clearance sponsored by
(Name of agency)

Subject

retired/separated or

will retire/separate from
(Name of agency)

(Date)

The agency security official (or office) holding the record of subject's (previous or current) clearance is
(Name of individual and/or office)

(Telephone and/or email address)

NOMINATOR:

DATE:
X
(SIGNATURE)

DIVISION DIRECTOR, POD:

Concur

X
(SIGNATURE)

DATE:

Non-Concur

Paperwork Burden Notice: The public reporting burden for this form is estimated to be 10 minutes. The burden estimate includes time
for reviewing instructions, researching existing data sources, gathering and maintaining the needed data, and completing and submitting the
form. Your response is voluntary. You are not required to respond to this collection of information unless a valid OMB control number is
displayed. Send comments regarding this burden estimate or any other aspect of this informtion collection, including suggestions for
reducing this burden to DHS/NPPD/Partnership and Outreach Divison, MS 8530, 245 Murray Lane SW, Bldg 410, Washington DC
20528. ATTN: PRA (1670-XXXX). NOTE: DO NOT send your completed form to this address.
Privacy Statement: Authority: Section 201 of the Homeland Security Act; Executive Order 12958 (as amended by Executive Order
13292); and Executive Order 12968 authorizes the collection of this information.
Purpose: DHS will use this information to conduct a background investigation and potentially grant a security clearance to the individual.
DHS will maintain the roster of program members for contact purposes and to facilitate information sharing.
Routine Uses: Information will be shared with the Office of Personnel Management to conduct background investigations. Contact
information may be shared with other Federal partners on a need to know basis.
Disclosure: Participation in the program is voluntary; however, failure to provide personally identifiable information may prevent the
individual from participating in the program or receiving a security clearance.
DHS Form 9014 (9/07)