Form DHS Form 9014 DHS Form 9014 Critical Infrastructure Private Sector Clearance Program

DEPARTMENT OF HOMELAND SECURITY

Critical Infrastructure Private Sector Clearance
Program Request

OMB No. 1670-0013
Expiration Date: 11/30/2011
**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 LEGAL NAME:

DATE:

COMPANY NAME/ADDRESS:

SECTOR:

LEVEL OF
CLEARANCE:

RECIPROCITY/REINSTATEMENT?

YES

SECRET
PHONE:

NO

EMAIL ADDRESS:

BACKGROUND INFORMATION
DATE OF BIRTH:

PLACE OF BIRTH:

SOCIAL SECURITY NUMBER:

U.S. CITIZEN:

YES

NO

JUSTIFICATION:

Subject serves as

(Position within company)

include

. Subject's responsibilities

.
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 all of the below requested information ONLY if you previously held an active clearance within the last 24 months.
previously held
currently holds a
Secret
Top Secret clearance sponsored by
Subject
Subject

retired/separated or

(Name of agency)

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)

NOMINATOR: PSA, IP SS, SSA

(Telephone and/or email address)

DATE:

X
(SIGNATURE)

A/S FOR INFRASTRUCTURE PROTECTION:
X

Concur
(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 information collection, including suggestions
for reducing this burden to DHS/NPPD/Partnership and Outreach Division, MS 8530, 245 Murray Lane SW, Bldg 410,
Washington DC 20528. ATTN: PRA (1670-0013). NOTE: DO NOT send your completed form to this address.
Privacy Statement: Authority: Section 201 of the Homeland Security Act; Executive Orders 12968, 13526, and 13549 authorize 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 (5/11)
Page 1 of 1

INSTRUCTIONS FOR COMPLETING DHS FORM 9014
FULL NAME: Enter your full legal name (First, Middle, Last).
DATE: Enter today's date.
COMPANY NAME/ADDRESS: Enter your company name and address where you receive your business mail.
SECTOR: Select one of the 18 CIKR Sectors utilizing the drop-down menu.
RECIPROCITY/REINSTATEMENT: Check “yes” ONLY if you have a current clearance or if your prior security clearance
was active within the last 2 years.
PHONE: Enter your 10-digit work phone number.
EMAIL ADDRESS: Enter your work email address.

BACKGROUND INFORMATION
** DATE OF BIRTH: LEAVE BLANK. You will be contacted directly by a DHS Security Specialist after you have been
approved for security clearance processing.
** PLACE OF BIRTH: LEAVE BLANK. You will be contacted directly by a DHS Security Specialist after you have been
approved for security clearance processing.
** SOCIAL SECURITY NUMBER: LEAVE BLANK. You will be contacted directly by a DHS Security Specialist after you
have been approved for security clearance processing.
U.S. CITIZEN: You must be a U.S. citizen to process for a DHS Security Clearance. If you are not a U.S. Citizen, please do
not complete the form and inform the person that nominated you.
JUSTIFICATION: On the first line, enter your position within your company. On the second line, include your job
responsibilities. On the third line, include any relevant association memberships (SCC, ISAC, etc). On the fourth line,
please list the sector you are affiliated with (should be the same as the sector chosen from the drop-down menu at the top
of the form).
PRIOR/CURRENT CLEARANCE INFORMATION SECTION: Please indicate whether you previously held/currently hold a
clearance, the level of clearance, and the Agency sponsoring the clearance. Please indicate your separation date from the
Agency sponsoring your clearance and provide a point of contact in that Agency's security office and their contact
information.
NOMINATOR: The DHS Federal Employee who is requesting the clearance and confirming the applicant's “need-to-know”.
The nominator will sign and date.
A/S FOR INFRASTRUCTURE PROTECTION: The Assistant Secretary for Infrastructure Protection will either concur or
non-concur with the request from the nominator. The A/S will sign and date.

UPON COMPLETION OF THIS FORM
Email the completed form to the DHS Federal employee who is nominating you for the security
clearance.