Form SSF 3237 SSF 3237 U.S. Secret Service Facility Access Request

Form Approved: O.M.B. Control No. 1620-0002, Expiration Date: 08/31/2016

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

3. CONTACT'S USSS E-MAIL ADDRESS

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

4. COMPANY/AGENCY AND POSITION TO BE HELD OR OTHER DUTIES PERFORMED

5. USSS CONTRACT NUMBER (required for all contractors)

6. IS THIS A CLASSIFIED PROGRAM/CONTRACT?

YES

NO

DOES THE APPLICANT HAVE A DD-254 ON FILE?

YES

NO

7. TYPE OF APPLICANT
CONTRACTOR

DETAILEE/JDA

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

OTHER:

8. SPECIFY THE TYPE OF ACCESS THAT THIS APPLICANT REQUIRES (you must select one category):
CATEGORY 1 (NON ROUTINE FACILITY ACCESS/ NO ACCESS TO INFORMATION TECHNOLOGY (IT) /NO ACCESS TO PERSONALLY
IDENTIFIABLE INFORMATION (PII)).
CATEGORY 1 ACCESS GRANTS THE APPLICANT TWO YEAR ACCESS.
IF LESS THAN TWO YEARS ACCESS, PLEASE INDICATE ACCESS EXPIRATION DATE:
CATEGORY 2 (ROUTINE FACILITY ACCESS AND NO IT ACCESS OR ACCESS TO PII).
CATEGORY 2 ACCESS GRANTS THE APPLICANT FIVE YEAR ACCESS.
IF LESS THAN FIVE YEARS ACCESS, PLEASE INDICATE ACCESS EXPIRATION DATE:
CATEGORY 3 (IT ACCESS AND/OR ACCESS TO PII REGARDLESS OF FACILITY ACCESS).
CATEGORY 3 ACCESS GRANTS THE APPLICANT FIVE YEAR ACCESS.
IF LESS THAN FIVE YEARS ACCESS, PLEASE INDICATE ACCESS EXPIRATION DATE:
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

HEIGHT

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

WEIGHT

EYE COLOR

HAIR COLOR

7. DRIVERS LICENSE NO. AND STATE

9. RACE

Female

American Indian or Alaskan Native
Asian

Male

Black or African American

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

11. DO YOU HAVE AN
UNEXPIRED DHS PIV
CARD?

Hispanic or Latino
Native Hawaiian or other
Pacific Islander
White

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

YES

NO
Cellular:

13. NAME AND ADDRESS OF EMPLOYER (company/agency)
Company name:

14. LENGTH OF TIME YOU
WORKED FOR THIS
EMPLOYER

Street address:

Years

City, State, ZIP:

Months

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

NO

15. NAME OF SUPERVISOR AND TELEPHONE NUMBER (with area code)

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

18. HAVE YOU EVER BEEN ARRESTED, CHARGED,
OR INDICTED FOR A CRIME?
YES

NO

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

NO

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

NO

SECTION B CONTINUES ON PAGE 2
SSF 3237 (Rev. 08/2016)

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Form Approved: O.M.B. Control No. 1620-0002, Expiration Date: 08/31/2016

SECTION B - CONTINUED FROM PAGE 1
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.
22. DATE

21. SIGNATURE OF APPLICANT

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 must submit this completed form to the U.S.
Secret Service Security Management Division at least five business days prior to the anticipated access date for
Category 1 applicants. For Category 2 and Category 3 applicants, the USSS responsible office must submit this
completed form to the Security Management Division at least 10 business days prior to the anticipated access
date.
4. A DD-254 form is required for all contractor positions requiring a security clearance. By selecting "YES" for Section A,
Item 9, you are verifying that a DD-254 is on file for the contract identified in Section A, Item 5 (DD-254 requirements
are not applicable for detailees).
5. Note that the applicant must sign this form TWICE: once under the release statement at the top of this page, and again at
item 21.
6. If there are any questions regarding this form, please contact the Security Management 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
The estimated average burden associated with this collection of information is 15
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.
In accordance with 5 CFR 1320.5(b), a Government agency may not conduct or sponsor, and a person is not required to complete, a
collection of information unless the collection of information displays a valid OMB control number.

SSF 3237 (Rev. 08/2016)

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