DOE F 472.3 Foreign Citizenship Ack

DOE F 472.3
(07/2017)

United States Department of Energy
Foreign Citizenship Acknowledgment
The U.S. Department of Energy (DOE) has considered your foreign citizenship as it relates to eligibility for
an access authorization/security clearance under title 10, Code of Federal Regulations, Part 710, E.O.
12968 and the Government-wide Adjudicative Guidelines, as revised, approved by the President. In
accordance with these policies, exercising any right(s) associated with your foreign citizenship raises a
concern that could impact your eligibility for an access authorization/security clearance, now and in the
future.
You acknowledge that you are a citizen of the United States and ________________________ (print name
of foreign country). You further acknowledge the fact that exercising any right resulting from your foreign
citizenship, or through the foreign citizenship of a family member, unless specifically authorized in advance,
in writing, by your servicing DOE Cognizant Personnel Security Office may result in the suspension
and/or revocation of your access authorization/security clearance. This includes, but is not limited to:
1. Possession, acquisition or use of a foreign passport.
2. Military service or a willingness to bear arms for a foreign country.
3. Accepting educational, medical, retirement, social welfare, or other such benefits from a
foreign country.
4. Residence in a foreign country to meet citizenship requirements.
5. Using foreign citizenship to protect financial or business interests in another country.
6. Seeking or holding political office in a foreign country.
7. Voting in a foreign election.
8. Action to acquire or obtain recognition of a foreign citizenship.
9. Performing or attempting to perform duties, or otherwise acting, so as to serve the interests of a
foreign person, group, organization, or Government in conflict with United States national
security interests.
10. Any statement or action that shows allegiance to a country other than the United States.

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Printed Full Name

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Signature

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Date