Form DHS Form 9014 DHS Form 9014 DHS Form 9014 Private Sector Clearance Program Request

DEPARTMENT OF HOMELAND SECURITY

CRITICAL INFRASTRUCTURE PRIVATE SECTOR CLEARANCE OMB No. 1670-0013
Expiration Date: 11/30/2011
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.
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

. Subject's responsibilities

(Position within company)

include
.
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.
Subject

currently holds a

previously held

Secret

Top Secret clearance sponsored by

(Name of agency)

Subject

retired/separated or

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)

(Telephone and/or email address)

NOMINATOR: PSA, IP SS, SSA

DATE:
X
(SIGNATURE)

A/S FOR INFRASTRUCTURE PROTECTION:

Concur

X
(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/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 (5/11)

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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-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.

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

DHS Form 9014 (5/11)

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