U.S. Secret Service Facility Access Request

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)

3. TELEPHONE NUMBER (with area code)

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

5. FREQUENCY OF ACCESS REQUIRED (circle one)

950 H STREET

TSD

JJRTC

V STREET

RDS

WFO

1111 18TH STREET

OTHER:

SSD
DAILY

6. POSITION TO BE HELD OR DUTIES TO BE PERFORMED

0 - 3 months
8. TYPE OF APPLICANT

CONTRACTOR

WEEKLY

MONTHLY

OTHER

7. LENGTH OF WORK TO BE PERFORMED, OR DURATION OF ACCESS

3 - 6 months

GOVERNMENT EMPLOYEE OUTSIDE OF THE SECRET SERVICE
(frequent visitor for official business)

DETAILEE/JDA

6 - 9 months

1 year

OTHER:

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)

HEIGHT

WEIGHT

EYE COLOR

HAIR COLOR

7. DRIVERS LICENSE NO. AND STATE

9. RACE

Female
Male
LENGTH OF TIME AT THIS
ADDRESS

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

Hispanic or Latino

Asian

Native Hawaiian or other Pacific
Islander

Black or African American

White

11. TELEPHONE (area code, number)
Work:

Years

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?

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

YES

(circle one)

NO

Date of Issuance:

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

SSF 3237 (Rev. 02/2013)

22. DATE

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

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.
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 Contractor Personnel Access Application and Release Statement 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 (Rev. 02/2013)

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