Form SSF 3237 SSF 3237 Contractor Personnel Access Application

Form Approved: O.M.B. No. 1620-0002, Expiration Date:

DEPARTMENT OF HOMELAND SECURITY

United States Secret Service

U.S. SECRET SERVICE FACILITY ACCESS REQUEST
PLEASE READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM
SECTION A - TO BE COMPLETED BY THE U.S. SECRET SERVICE RESPONSIBLE OFFICE
1. NAME OF USSS RESPONSIBLE OFFICE

2. USSS POINT OF CONTACT (Last, First, Middle)

4. SITE(S) OR FACILITY(S) TO BE ACCESSED BY REQUESTOR

3. TELEPHONE NUMBER (with area code)

5. FREQUENCY OF ACCESS REQUIRED (check one)

950 H STREET

TSD

JJRTC

V STREET

RDS

WFO

1111 18TH STREET

OTHER:

SSD

DAILY

WEEKLY

MONTHLY

OTHER

6. LENGTH OF WORK TO BE PERFORMED, OR DURATION OF ACCESS
0 - 3 months

3 - 6 months

6 - 9 months

1 year

7. POSITION TO BE HELD OR DUTIES TO BE PERFORMED

8. USSS CONTRACT NUMBER (required for all contractors)

9. TYPE OF APPLICANT

OTHER:
GOVERNMENT EMPLOYEE OUTSIDE OF THE SECRET SERVICE
(frequent visitor for official business)
10. FOR ALL CONTRACTORS PERFORMING WORK ON UNCLASSIFIED CONTRACTS PLEASE INDICATE THE POSITION SENSITIVITY LEVEL BELOW.
(For contractors performing work on classified USSS contracts, skip this section and go directly to item 11.)
CONTRACTOR

DETAILEE/JDA

Instructions: One of the five boxes must be checked for every contractor, but check only one box. For example, if a contractor is performing services for the USSS other than IT support, it must be either 1N,
5N, or 6N; however, for those who provide IT development, IT engineering, or IT administration support for TEC, IRM, CIO, etc., then 5C or 6C would be required. *Low Risk (1N/1C) is for building access only.
No access to USSS IT systems is required.)
NON-IT POSITION RISK LEVEL:

LOW RISK* (1N)

MODERATE RISK (5N)

HIGH RISK (6N)

IT POSITION RISK LEVEL:

LOW RISK* (1C)

MODERATE RISK (5C)

HIGH RISK (6C)

11. FOR CLASSIFIED CONTRACTS PLEASE INDICATE THE POSITION SECURITY CLEARANCE REQUIREMENT BELOW.
(This item should be completed for USSS classified contracts only.)
Instructions: A DD-254 form is required for all contractor positions requiring a security clearance. By selecting "YES" in the "DD-254 ON FILE?" box below, you are verifying that a DD-254 is on file for the
contract identified above. For positions not requiring a clearance, please indicate a Position Sensitivity Level in item 10 above.

SECURITY CLEARANCE LEVEL REQUIRED:

SECRET (2C/2N)

TOP SECRET (3C/3N)

SCI (4C/4N)

DD-254 ON FILE?

YES

SECTION B - TO BE COMPLETED BY APPLICANT
1. FULL NAME (last, first, middle)

2. MAIDEN NAME (if applicable)

3. OTHER ALIAS (last, first, middle)

4. SOCIAL SECURITY NUMBER

5. DATE OF BIRTH (month/day/year)

8. SEX

6. PLACE OF BIRTH (city, state, country)

WEIGHT

HEIGHT

HAIR COLOR

EYE COLOR

7. DRIVERS LICENSE NO. AND STATE

9. RACE

Female
Male
10. PRESENT ADDRESS (street address, city, state, zip code)

LENGTH OF TIME AT THIS
ADDRESS
Years

Hispanic or Latino

Asian

Native Hawaiian or other Pacific
Islander

Black or African American

White

11. TELEPHONE (area code, number)
Work:
Residence:

Months
12. MARITAL STATUS

American Indian or Alaskan Native

Cellular:

13. SPOUSE'S NAME AND ADDRESS (if applicable)

14. NAME AND ADDRESS OF EMPLOYER (company/agency)

LENGTH OF TIME YOU WORKED 15. NAME OF SUPERVISOR AND TELEPHONE NUMBER (with area code)
FOR THIS EMPLOYER
Years
Months

16. DO YOU HOLD U.S. CITIZENSHIP STATUS?
YES

(circle one)

NO

17. IF YOU ARE A U.S. CITIZEN OTHER THAN BY BIRTH, PROVIDE THE FOLLOWING:
Naturalization Certificate No.:
Date of Issuance:

SECTION B CONTINUES ON PAGE 2
SSF 3237 (DRAFT Rev. 06/2013)

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Form Approved: O.M.B. No. 1620-0002

SECTION B - CONTINUED FROM PAGE 1
18. HAVE YOU EVER BEEN ARRESTED, CHARGED, OR
INDICTED FOR A CRIME?
YES

(circle one)

19. HAVE YOU EVER BEEN CONVICTED OF ANY
CRIMINAL OFFENSE?

NO

YES

(circle one)

20. ARE THERE ANY PENDING CHARGES AGAINST YOU
BEFORE A CIVIL OR CRIMINAL COURT?

NO

YES

(circle one)

NO

RELEASE STATEMENT - TO BE COMPLETED BY APPLICANT
This release when presented by a duly authorized representative of the U. S. Secret Service will constitute my consent and authority to obtain any information relating to my activities
from criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail businesses, or other sources of information. The information may include my
criminal history record information and financial and credit information.
Specifically, I hereby authorize the release of Federal/State/Local Police & Criminal Records or data to the U.S. Secret Service by applying my signature on the designated line below.
My signature further authorizes the U.S. Secret Service (or other component of the Department of Homeland Security) to obtain one or more consumer credit reports about me
pursuant to the Fair Credit Reporting Act from any consumer credit reporting agency. Copies of this authorization that show my signature are as valid as the original signed by me.

(signature of applicant)
This authorization is given in connection with the investigative procedures being conducted relative to my contractual services with the U.S. Secret Service, and/or access to secure
areas occupied by the U.S. Secret Service.

NOTE: I understand than any false statement on any part of my application may be grounds for denying me access
into Secret Service controlled facilities, and/or grounds for prosecution under Title 18 U.S.C. 1001.
21. SIGNATURE OF APPLICANT

22. DATE

INSTRUCTIONS:

1. Please TYPE or PRINT clearly with a dark ball point pen.
2. To apply for access into U.S. Secret Service controlled facilities, the applicant must complete this form in
its entirety. (Failure to properly complete this form can result in delays and/or non admittance into U.S.
Secret Service controlled facilities.) Note that the applicant must sign this form TWICE: once under the release
statement and again at item 21.
3. A representative from the U.S. Secret Service Responsible Office should submit this completed form to the U.S.
Secret Service Security Clearance Division at least five days prior to the anticipated access date.
4. If there are any questions regarding this form, please contact the Security Clearance Division at (202) 406-6658.

Privacy Act Statement: All information requested on the U.S. Secret Service Facility Access Request is collected under authority
derived from 18 U.S.C. 3056 and Executive Order 9397. The routine uses of information requested include referral to other Federal,
State and Local agencies for determining suitability for access to secure areas, and/or sensitive, unclassified material of the U.S. Secret
Service. Submission of the information is voluntary, however, failure to provide information requested may prohibit processing and
cause denial of access to secure areas or sensitive material protected by the U.S. Secret Service. Disclosure of your Social Security
Account Number is voluntary. The information is used to identify and separate individuals with similar or identical names or initials.
Refusal to disclose your Social Security Number will be no cause for denial of any right, benefit or privilege provided by law.
PUBLIC BURDEN INFORMATION

15
The estimated average burden associated with this collection of information is
minutes per respondent or recordkeeper.
Comments and or suggestions concerning the accuracy of this burden estimate and for reducing this burden should be directed to
the Secret Service at this address: Communications Center (MNO), 245 Murray Lane, SW, Building T5, Washington, DC 20223; and to
the Office of Management and Budget, Paperwork Reduction Project (1620-0002), Washington, DC 20503. An agency may not
conduct or sponsor, and a person is not required to, a collection of information unless the collection of information displays a valid OMB
control number.

SSF 3237 (DRAFT Rev. 06/2013)

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