Form DHS Form 9012 DHS Form 9012 Chemical-terrorism Vulnerability information Training &

Department of Homeland Security Chemical-terrorism Vulnerability Information Training & Authorized User Application

OMB Control Number 1670-0015 Expiration Date 03/31/2013

Burden Statement

The public reporting burden for the Chemical-terrorism Vulnerability Information (CVI) Training and Authorized User Application is estimated to be 1 hour. The burden estimate includes time for reviewing instructions, researching existing data sources, gathering and maintaining the needed data, and completing and submitting the form. You may send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to:

DHS/NPPD/IP/ISCD

Attention: CFATS Program Manager

245 Murray Lane SW,

Mail Stop 0610

Arlington, VA 20528-0610

Completion of the CVI Training and Authorized User Application is mandatory for all covered persons. See Section 550 of P.L. 109- 295 and the implementing regulations, 6 CFR Part 27.

You are not required to respond to this collection of information (i.e., the CVI Training and Authorized User application) unless a valid OMB control number is displayed. NOTE: DO NOT send the completed CVI Authorized User application to the above address.

Instructions

Please complete the CVI Training, read and affirm the statements, and complete the Authorized User application below. Failure to not fully complete the application will result in your application to be a CVI Authorized User not being considered.

DHS will review the application, and if approved, provide to you a unique CVI Authorized User number to confirm your status.

I hereby acknowledge that I am familiar with and that I will comply with all CVI requirements set out in:

• Section 550 of Public Law 109-295 (as amended);

• 6 CFR Part 27; and

• any other requirements that may be officially communicated to me by the Department of Homeland Security (DHS).

I hereby acknowledge that I am familiar with or have been provided access to the DHS Procedural Manual entitled “Safeguarding Information Designated as Chemical-terrorism Vulnerability Information (CVI).”

I hereby acknowledge that if I violate the requirements of 6 CFR § 27.400 for protection of CVI, I may be subject to civil penalties or other enforcement or corrective action by DHS, such as orders to retrieve any CVI improperly disclosed or to prevent future unauthorized disclosures (including revocation of my CVI Authorized User status).

First Name: Middle Initial:

Last Name:

Organization Name:

Organization Type: (Choose One)

Chemical Facility employee	DHS Employee	State or local gov’t. employee
Chemical Facility contractor	Federal gov’t employee	State or local gov’t contractor
Vested Private Third Party	Federal gov’t contractor	Other:

Business Mailing Address:

City: State: Zip Code:

Telephone: Ext: Email:

Describe Official Duties:

Direct Supervisor’s Name:

Supervisor’s Telephone: Ext:

Privacy Act Statement:

Authority: 5 U.S. C. § 301 and 44 U.S.C. § 3101 authorize the collection of this information.

Purpose: DHS will use this information to register you as a Chemical-terrorism Vulnerability Information (CVI) Authorized User, issue your unique CVI identification number, verify your CVI Authorized User status or contact you regarding your submission.

Routine Use: This information may be disclosed as generally permitted under 5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended. This includes using the information, as necessary and authorized by the routine uses published in DHS/ALL-004 General Information Technology Access Account Records System of Records (September 29, 2009, 74 FR 49882).

Disclosure: Furnishing this information is voluntary; however failure to provide any of the information requested may result in you not becoming a CVI Authorized User, not being able to verify your CVI Authorized User status or not being able to contact you regarding your submission.

DHS Form 9012 (09/08) 4