Form DHS 9014 DHS 9014 CRITICAL INFRASTRUCTURE PRIVATE SECTOR CLEARANCE PROGRAM

DEPARTMENT OF HOMELAND SECURITY

CRITICAL INFRASTRUCTURE PRIVATE SECTOR CLEARANCE OMB No. 1670-0013
Expiration Date: 01/31/2015
PROGRAM REQUEST
**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.

SUBJECT INFORMATION
FULL LEGAL NAME (First, Middle, Last, Suffix):

TODAY'S DATE:

COMPANY NAME AND ADDRESS:

PHONE:
EMAIL ADDRESS:

NOMINEE IS CURRENTLY A MEMBER OF:
OTHER:

CLEARANCE LEVEL:

JUSTIFICATION
NOMINEE'S JOB TITLE/POSITION: (Do not use acronyms)

U.S. CITIZEN:
YES

Has the Chief Security Officer of the company been notified of the nomination?
YES
NO
Phone or e-mail:
Please provide CSO contact information. Name:
Is there a secure facility within 50 miles where a clearance holder may attend a classified briefing?
No
No, but I'm willing to travel
Yes

NO

N/A

Nominee satisfied the following criteria (from EO 13549 Section 5.g):
Corporate owners and operators determined by the Secretary of Homeland Security to be part of the Critical Infrastructure;
Subject matter experts selected to assist with Federal or State Critical Infrastructure Security and Resilience;
Personnel serving in specific leadership positions of Critical Infrastructure coordination, operations, and oversight;
Employees of corporate entities relating to the protection of Critical Infrastructure;
Other persons not otherwise eligible for the granting of a personnel security clearance pursuant to Executive Order 12829, as amended, who
are determined by the Secretary of Homeland Security to require a personnel security clearance.
Nominee'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
Further justification, to include Nominee's responsibilities and association memberships:

*Provide all of the below requested information ONLY if you previously held an active clearance within the last 24 months.
previously held
Nominee
currently holds a
Secret
Top Secret clearance
Sponsored by (Name of Agency):
Contact Information of Security Official/Office:
Phone Number:
Nominee

retired/separated or

E-mail:

will retire/separate from:

Date of retirement/separation:

Reciprocity/Reinstatement?

YES

NO

For Periodic Reinvestigations: Has clearance
holder used his/her PSCP clearance?

(Check “yes” ONLY if you have a current
clearance or if your prior security clearance
was active within the last 2 years)

NOMINATION INFORMATION
NOMINATOR NAME:

SIGNATURE:

DATE:

Position:
A/S FOR INFRASTRUCTURE PROTECTION:
Concur
Non-Concur

X
SIGNATURE:
X

DATE:

DO NOT COMPLETE BELOW THIS LINE
DATE OF BIRTH:

PLACE OF BIRTH:

SOCIAL SECURITY NUMBER:

MAILING ADDRESS (optional):

DHS Form 9014 (12/14)

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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/IP/PSCP, Mail Stop 0609, 245 Murray Lane SW, Bldg 410, Washington DC 20598. ATTN: PRA (1670-0013)
NOTE: DO NOT send your completed form to this address.
Privacy Act Statement:
Authority: Section 201 of the Homeland Security Act and Executive Orders 9397, 12968, 13526, and 13549 authorize the collection of this
information.
Purpose: The primary purpose of this collection is to facilitate the background investigations required to potentially grant a security clearance to an
individual partner, serving as a subject matter expert within a specific industry and possessing knowledge not available within DHS. 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, as necessary and
authorized by the routine uses published in DHS/ALL-023 - Department of Homeland Security Personnel Security Management, 74 FR 3084
(January 16, 2009). Contact information may be shared with other Federal partners as necessary and authorized by the routine uses published in
DHS/ALL-002 - Department of Homeland Security Mailing and Other Lists System, 73 FR 71659 (November 25, 2008).
Disclosure: Participation in the program is voluntary; however, failure to provide this information may prevent the individual from participating in the
program or receiving a security clearance.

DHS Form 9014 (12/14)

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INSTRUCTIONS FOR COMPLETING DHS FORM 9014
FULL NAME: Enter your FULL legal name (First, Middle, Last, Suffix).
DATE: Enter today's date.
COMPANY NAME/ADDRESS: Enter your company name and address where you receive your business mail.
PHONE: Enter your 10-digit work phone number.
EMAIL ADDRESS: Enter your work email address.
MEMBER OF: Enter relevant National Infrastructure Protection Plan Framework Counsel membership.
CLEARANCE LEVEL: Select requested clearance level from the drop down list. The level of access granted shall not
exceed the secret level, unless the sponsoring agency determines on a case-by-case basis that the applicant has a
demonstrated and foreseeable need for access to Top Secret, Special Access Program, or Sensitive Compartmented
Information.

BACKGROUND INFORMATION

NOMINEE'S JOB TITLE/POSITION: Enter your job title/responsibilities.

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.
CHIEF SECURITY OFFICER (CSO): If appropriate, identify if the company CSO (or the executive otherwise responsible
for your organization's security posture) has been notified of the request. Provide their name and work phone or official
e-mail address.
SECURE FACILITY: Identify proximity of secure facility or ability to travel for classified briefing
EXECUTIVE ORDER (EO) CRITERIA: Select the criteria that most defines your role/responsibility within your company
SECTOR: Select your sector affiliation
FURTHER JUSTIFICATION: Provide further justification to include Subjects roles and responsibilities and additional
association memberships.
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.
RECIPROCITY/REINSTATEMENT: Check “yes” ONLY if you have a current clearance or if your prior security clearance
was active within the last 2 years.
NOMINATOR: The authorized Federal Employee who is requesting the clearance and confirming the applicant's “need-toknow”. 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.
** DATE OF BIRTH / PLACE OF BIRTH / SOCIAL SECURITY NUMBER: LEAVE BLANK. You will be contacted directly
by a DHS Security Specialist after you have been approved for security clearance processing.
** MAILING ADDRESS (Optional): LEAVE BLANK. There will be an option for the DHS Security Specialist to collect an
alternate mailing address if you prefer finger print cards to be mailed to an address other than your company address.

UPON COMPLETION OF THIS FORM
Email the completed form to the authorized Federal employee who is nominating you for the security clearance.
DHS Form 9014 (12/14)

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