Exchange Form 3900 e-QIP Request Form

OMB NO. 0702OMB approval expires
MMM DD, YYYY

e‐QIP REQUEST FORM
(Electronic Questionnaires for Investigations Processing)

AGENCY DISCLOSURE NOTICE

RA
FT

The public reporting burden for this collection of information is estimated to average 40 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to
the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives
Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0702-XXXX).
Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any
penalty for failing to comply with a collection of information if it does not display a currently valid OMB
control number.
PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.

Responses should be sent to the Exchange CS‐FP at 3911 South Walton Walker Blvd., Dallas, TX  75236‐1598. 

PRIVACY ACT STATEMENT

AUTHORITY: Title 10, U.S.C. 3013, Secretary of the Army; Title 10 U.S.C. 8013, Secretary of the Air Force;
Army Regulation 215-8/Air Force Instruction 34-211(I) Army and Air Force Exchange Service Operations;
Army Regulation 380.37, Personnel Security Program; Air Force Instruction 31-501, Personnel Security
Program Management; Department of Defense 5200.2-R, “Personnel Security Program; Air Force Instruction
31-401, Information Security Program Manager; E.O. 12065 and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSES: To assist in the processing of personnel security clearance actions; to record
security clearances issued or denied, and to verify for access to classified information or assignment to a
sensitive position.

D

ROUTINE USES: Records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3)
regarding DoD “Blanket Routine Uses” published at
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. Information may be released
to Federal agencies based on formal accreditation as specified in official directives; regulations; to
Federal, State, Local, and Foreign Law Enforcement, Intelligence, or Security agencies in connection
with a lawful investigation under their jurisdiction.

DISCLOSURE: Voluntary, however, failure to provide information may result in denial of a Common Access
Card; non-enrollment in the Defense Enrollment Eligibility Reporting System
(DEERS); refusal to grant access to DoD installations, buildings, facilities, computer systems and networks; and
denial of DoD benefits if otherwise authorized. 

EXCHANGE 

Army & Air Force Exchange Service  

(Electronic Questionnaires for Investigations Processing) 

Please type or write legibly 

e‐QIP REQUEST FORM   

OMB NO. 0702‐ 
OMB approval expires 
MMM DD, YYYY 

Instructions:
Before completing, please read the Disclosure Notice and the Privacy Act Statement on page one.
This form will be used as a checklist to be certain all information is collected to complete your official background
investigation.
3. Exchange associates check the “Exchange” box in Section I and complete Sections I, II, III and IV. Section VI will be
complete by your supervisor or HR Representative.
4. Contractors check the “Contractor” box in Section I and complete Sections I, II and III. Section V and VI will be
completed by your Contract Official.
5. Please follow all directions provided by your HR Representative or Contract Official.
6. Provide all documents listed in section VI to your HR Representative or Contract Official who will review and forward to
the appropriate office for processing.
I. EXCHANGE/CONTRACTOR

RA
FT

1.
2.

Choose One:

Contractor

Exchange

Date of Request: (ex: 25 Ju/1985) __________________________________________________

II. APPLICANT'S INFORMATION

(FULL NAME) LAST:

FIRST:

MIDDLE:

GENDER:

Male

DATE OF BIRTH: (ex: 25 JUL 1985)

Female

PLACE OF BIRTH: (City, State) OR (City, County, overseas only)

SOCIAL SECURITY #:

Work Location:

Region:

E-MAIL ADDRESS:

PHONE #:

POSITION TITLE:

Is your job associated with Firearms?

Exchange Hire Date:

NO

YES

Ill. PRIOR MILITARY/OTHER FEDERAL AGENCY

Choose One:
Military/Federal Agency (within 24 months)

NO

YES

Service: _______________________________________________

From: (Month/Year)______________To: (Month/Year)__________________

IV. EXCHANGE PERSONNEL ONLY

SUPERVISOR NAME:

PHONE NUMBER / E-MAIL ADDRESS:

(EXTENSION #)

HUMAN RESOURCE MANAGER NAME:

PHONE NUMBER / E-MAIL ADDRESS:

(EXTENSION #)

v.

EXCHANGE POC NAME:

EXCHANGE CONTRACTING OFFICER ONLY
PHONE #:

FACILITY #:

PHOINE #:

CONTRACTOR’S POC NAME:

CONTRACT # / PO #:

CONTRACTING COMPANY NAME:

COMPANY’S POC E-MAIL ADDRESS:

D

VI. REQUIRED DOCUMENTS*

Choose Type of Fingerprint Submission and Include: Local Police Report and OF 306
Electronic Fingerprints Transmission Date:

Fingerprint Card
(SF87 Rev. March 2013)

(ex : 25 JUL 1985)

Resume I Application

OF 306

Local Police Report

FedEx this completed form with the hardcopy fingerprint card and police report to:
Exchange (EG/CS-FP)
3911 S. Walton Walker Blvd.
Dallas, IX 75236-1598

VII. EXCHANGE CS-FP ONLY

INITIATOR / REVIEWER / APPROVER:

DATE: (DD/MMM/YYYY)

STATUS:

INITIATOR / REVIEWER / APPROVER:

DATE: (DD/MMM/YYYY)

STATUS:

COMMENTS:

EXCHANGE FORM 3900-013 (DRAFT)

*(Request will not be processed without the required documents and If not completed property.)