DD Form 2962-1 Personnel Security System Access Request Form

PERSONNEL SECURITY SYSTEM ACCESS REQUEST (PSSAR)

OMB No. XXXX-XXXX
OMB approval expires
XXXXXXX

DEFENSE MANPOWER DATA CENTER (DMDC)
JPAS ACCESS

The public reporting burden for this collection of information is estimated to average 10 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 tthe Department of Defense, Washington Headquarters Services, at [email protected]. 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.

Return completed form to the appropriate Account Manager or DMDC Contact Center, as indicated in the instructions.
PRIVACY ACT STATEMENT
AUTHORITY: DoD 5200.2-R, Department of Defense Personnel Security Program Regulation; E.O. 12829, National Industrial Security Program; the JPAS
Account Management Policy; and E.O. 9397, as amended.
PRINCIPAL PURPOSE(S): To request the establishment of user roles and access and validate the trustworthiness of individuals seeking access to DCII,
SWFT, JCAVS, or JAMS.
ROUTINE USE(S): The blanket routine uses found at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx may apply.
DISCLOSURE: Voluntary. However, failure to provide the requested information may impede, delay, or prevent further processing of your request. The
Social Security Number is used to verify the trustworthiness status in JPAS.
TYPE OF REQUEST (REQUIRED)
INITIAL

MODIFICATION

DATE (YYYYMMDD)
DEACTIVATE

USER ID (EXISTING ACCOUNTS) _________________

PART 1 - PERSONAL INFORMATION
1. NAME (LAST, FIRST, MIDDLE INITIAL)

2. ORGANIZATION

3. OFFICE SYMBOL/DEPARTMENT

4. TELEPHONE (DSN or COMMERCIAL)

5. OFFICIAL E-MAIL ADDRESS

6. JOB TITLE AND GRADE/RANK

7. OFFICIAL MAILING ADDRESS

8. CITIZENSHIP

10. PLACE OF BIRTH (CITY & STATE/COUNTRY)

11. SOCIAL SECURITY NUMBER

N E E D S

13. DESIGNATION OF APPLICANT

D D

DoD CIVILIAN

MILITARY

9. DATE OF BIRTH (YYYYMMDD)

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12. CAGE CODE (CTR ONLY)

NON-DoD

INDUSTRY

PART 2 - APPLICATIONS
14. DEFENSE CENTRAL INDEX OF INVESTIGATIONS (DCII) (GOVERNMENT ONLY)
a. DCII AGENCY CODE ______________________________________

OR

DCII AGENCY ACRONYM

______________________

b. USER PERMISSIONS
QUERY (SEARCH)

ADD

UPDATE

DELETE

FILE DEMAND (PROVIDE ACCREDITATION CODE): ______________

AGENCY ADMINISTRATOR

EXECUTIVE ADMINISTRATOR

FILE DEMAND PRINT

IA (ROOT ADMINISTRATOR)

15. SECURE WEB FINGERPRINT TRANSMISSION (SWFT) (GOVERNMENT/INDUSTRY)
a. PERMISSIONS - FINGERPRINT SUBMISSION
USER
MULTI-SITE UPLOADER

SITE ADMINISTRATOR

b. PERMISSIONS - FINGERPRINT ENROLLMENT
ENROLLER
TRANSACTION VIEWER

ENROLLER SITE ADMINISTRATOR

c. ADDITIONAL CAGE/ORGANIZATION CODE(S): ___________________________

ORGANIZATION/COMPANY ADMINISTRATOR
ENROLLER GROUP ADMINISTRATOR

OTHER:

16. JOINT CLEARANCE ACCESS VERIFICATION SYSTEM (JCAVS) (GOVERNMENT/INDUSTRY)
a. TYPE OF ACCOUNT REQUESTED:

ACCOUNT MANAGER

b. ACCESS REQUESTED - INDUSTRY:

c. ACCESS REQUESTED - GOVERNMENT ONLY:

LEVEL 2

CORPORATE OFFICER (SCI)

LEVEL 2

MACOM/ACTIVITY/HQ/AGENCY SSO

LEVEL 3

COMPANY FSO OFFICER/MANAGER (SCI)

LEVEL 3

BASE/POST/SHIP/etc. SSO

LEVEL 4

CORPORATE OFFICERS MANAGER

LEVEL 4

MACOM NON-SCI SECURITY MANAGER

LEVEL 5

COMPANY FSO OFFICERS/MANAGER

LEVEL 5

BASE/POST/SHIP/NON-SCI SECURITY MGR.

LEVEL 6

UNIT SECURITY MGR/VISITOR CONTROL

LEVEL 6

UNIT SECURITY MANAGER

LEVEL 7

GUARD ENTRY PERSONNEL

LEVEL 7

COLLATERAL ENTRY CONTROLLER

LEVEL 8

GUARD ENTRY PERSONNEL (SCI)

LEVEL 8

SCIF ENTRY CONTROLLER

LEVEL 10

VISITOR MANAGEMENT

LEVEL 10

VISITOR MANAGEMENT

d. PERMISSION REQUESTED:

INITIATE PSI

DD FORM 2962v1, 20180920 DRAFT

REVIEW e-QIP

OVERRIDE PSI

PREVIOUS EDITION IS OBSOLETE.

APPROVE e-QIP
Adobe Designer 11

NAME (LAST NAME, FIRST NAME, MIDDLE INITIAL) _________________________________________________
17. JOINT ADJUDICATION MANAGEMENT SYSTEM (JAMS) (DoD CAF ONLY)
a. USER ROLES
CAF:

CAF TEAM:

EMPLOYEE CODE:

b. ACCESS REQUESTED:

c. USER PERMISSIONS:

ACCOUNT MANAGER

CUSTOMER SUPPORT

SAP

CASE MANAGEMENT

MANAGER

ADJUDICATOR

SCI

UPDATE CASE COMPONENT

COMPUTER ANALYST

MANAGEMENT
SUPPORT

TS

ASSIGN CAF CASES

SECRET

REVIEW REQUIRED

PENDING USER

REPORTS

REASSIGN TO OTHER CAF

SUPERVISOR

JCAVS

ASSIGN/REASSIGN CASES

MAILROOM

LAA

REASSIGN FROM OTHER EMPLOYEE

CASE ASSIGNMENT
PERSONNEL
SECURITY ASSISTANT

d. SPECIAL CASE USER CAN HANDLE

CAF EMPLOYEES

PRESIDENTIAL SUPPORT

e. INVESTIGATION REQUEST PERMISSIONS

REVIEW PSQ

APPROVE e-QIP

GS-15/GENERAL OFFICER

PART 3 - TRAINING
I HAVE COMPLETED AND ATTACHED TRAINING CERTIFICATES FOR:
18.

CYBER AWARENESS TRAINING

DATE (YYYYMMDD) ________________

19.

PERSONALLY IDENTIFIABLE INFORMATION TRAINING

DATE (YYYYMMDD) ________________

20.

JPAS TRAINING REQUIREMENTS

DATE (YYYYMMDD) _______________

PART 4 - APPLICANT'S CERTIFICATION
I hereby certify that I understand that by signing this Personnel Security System Access Request, I am solely responsible for the use and
protection of the account that I will be provided. I also understand that I am not authorized to share my account or logon credentials with
any other individuals. I will utilize all tools and applications in accordance with the account management policy and security policy, as well
as all applicable U.S. laws and DoD regulations. I understand that if I violate any account management policy, security policy, U.S. laws or
DoD regulations, my account will immediately be terminated, I will no longer be responsible for an account, and may be subject to criminal
charges and penalties.

N E E D S

21. APPLICANT'S SIGNATURE

D D

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22. DATE (YYYYMMDD)

PART 5 - NOMINATING OFFICIAL'S CERTIFICATION
I certify that the above named individual meets the requirements for access, has the appropriate need-to-know, and if applicable, meets the
requirements for account management privileges. I am also aware that I am responsible for ensuring this individual will follow all account
policies, security policies, and all applicable DoD regulations and U.S. laws. Furthermore, I certify that the named Applicant requires
account access as indicated above in order to perform assigned duties. These duties include:

23. NOMINATING OFFICIAL'S PRINTED NAME (LAST, FIRST, MIDDLE
INITIAL)

24. NOMINATING OFFICIAL'S SIGNATURE AND DATE

25. NOMINATING OFFICIAL'S TITLE

26. NOMINATING OFFICIAL'S TELEPHONE NUMBER

PART 6 - VALIDATING OFFICIAL'S VERIFICATION
I have verified that minimum investigative requirements for the above Applicant have been met and the Applicant has the necessary needto-know to access the Personnel Security Systems requested.
27. ELIGIBILITY/ACCESS LEVEL:

28. TYPE OF INVESTIGATION:

29. ELIGIBILITY GRANTED DATE:

30. DATE INVESTIGATION COMPLETED:

31. ELIGIBILITY ISSUED BY:

32. INVESTIGATION CONDUCTED BY:

33. VALIDATING OFFICIAL'S PRINTED NAME (LAST, FIRST, MIDDLE
INITIAL)

34. VALIDATING OFFICIAL'S SIGNATURE AND DATE

DD FORM 2962v1 (BACK), 20180920 DRAFT

PERSONNEL SECURITY SYSTEM ACCESS REQUEST (PSSAR) INSTRUCTIONS
Please see the respective System Access Request Procedures available from the DMDC PSA website for supplemental guidance on completing and
submitting this form.
Name. Last Name, First Name, Middle Initial of Applicant. If no middle
initial, enter "NMN."
Type of Request. Select "initial" for a new account, "modification" for a
change in privileges to an existing account, "deactivate" to remove all
access and disable an existing account. Complete the User ID field if
selecting "modification" or "deactivate."
Date. Date request is submitted.

Part 1 - Personal Information.

17. Joint Adjudication Management System (JAMS). CAF only.
17.a. JAMS User Roles. Provide information and select appropriate boxes for
user functions, access and permissions. JAMS is only authorized for CAFs.
17.b. Access Requested. JAMS access requested.
17.c. User Permissions. JAMS user permission(s).
17.d. Special Case User Can Handle. Select high priority cases JAMS user can
handle.

1. Name. Last Name, First Name, Middle Initial of Applicant. If no
middle initial, enter "NMN."

17.e. Investigation Request Permissions. Select Investigation Request
permissions for JAMS user.

2. Organization. Employing organization of Applicant.

Part 3 - Training.

3. Office Symbol/Department. Employing office symbol or department.

18. - 20. Training Requirements. Mark (X) the box to certify training was
completed and enter the completion date for all new accounts. Training
requirements are defined in the respective System Account Management Policies
available from the DMDC PSA website. Certificates must be submitted with
PSSAR.

4. Telephone. Telephone number of Applicant. Enter DSN or
Commercial as appropriate.
5. Official E-mail Address. Official e-mail address of Applicant to be
used for account communication.
6. Job Title and Grade/Rank. Job title and pay grade or military rank of
Applicant.
7. Official Mailing Address. Official mailing address of Applicant.
8. Citizenship. Country of citizenship. If dual, enter both countries.

Part 4 - Applicant's Certification.
21. Applicant's Signature. Signature of Applicant acknowledging DoD and
system policies.
22. Date. Date application signed by Applicant.

9. Date of Birth. Applicant's date of birth.

Part 5 - Nominating Official's Certification.

10. Place of Birth. City and state, if born in the U.S. Otherwise, enter
country and city.

23. Nominating Official's Name. Last Name, First Name, and Middle Initial. If
no middle initial, enter "NMN."

11. Social Security Number. SSN of Applicant.

Part 2 - Applications.

24. Nominating Official's Signature and Date. The Nominating Official is the
individual who is authorizing that the Applicant should have the access requested.
For Industry, the Nominating Official must be listed in ISFD as a Key Management
Personnel (KMP) in connection with the Facility Clearance, and if an Appointment
Letter is needed, it must be signed by the same KMP. The Nominating Official
CANNOT be the same as the Applicant unless it is a single person facility. For
Government/Civilian, the Nominating Official must be the Security Officer/
Manager.

14. Defense Central Index of Investigations (DCII). Government
applicants only.

NOTE: PSSARs submitted without the Nominating Official's statement regarding
duties and signature will not be processed.

14.a. DCII Agency Code/DCII Agency Acronym. Complete if
requesting a DCII account. Provide the DCII Agency Code/DCII Agency
Acronym if previously assigned by DCII Administrator and known.
Otherwise, contact DMDC Contact Center for assistance

25. Nominating Official's Title. Title of Nominating Official.

14.b. User Permissions. Requested user permissions are restricted to
those granted to the Agency. Elevated permissions for the Agency must
be requested from DCII Program Manager.

Part 6 - Validating Official's Verification. Do not complete if self-

12. CAGE Code. Contractor only: CAGE code of Applicant.
13. Designation of Applicant. Mark (X) the appropriate box for DoD
(e.g., military branches, DoD agencies, DoD contractor companies), nonDoD NISP partner or non-DoD affiliated.

N E E D S

15. Secure Web Fingerprint Transmission (SWFT). For Government
and Industry applicants.
15.a. Permissions - Fingerprint Submission. Applies to SWFT users.
Indicate the requested user permission(s) by marking the appropriate
checkbox, or list in item 15.c. on line "Other.
15.b. Permissions - Fingerprint Enrollment. Indicate the requested
user permission(s) by marking the appropriate checkbox. Only complete
this section if you possess or requested a SWFT account (Government
only) and are cleared to use the web-based fingerprint enrollment
system.

D D

6 7

26. Nominating Official's Telephone Number. DSN or Commercial telephone
number of Nominating Official.
nominating/validating.
27. Eligibility/Access Level. Eligibility/Access level of Applicant. See
applicable System Account Management Policies/Access Request Procedures
available from the respective DMDC PSA system website for minimum eligibility/
access requirements.
28. Type of Investigation. Type of investigation completed for Applicant.
29. Eligibility Granted Date. Date eligibility granted. If not final, state date of
interim.
30. Date Investigation Completed. Date investigation completed.
31. Eligibility Issued By. Organization that issued eligibility.

15.c. Additional CAGE Code(s). List only if different from item 12 of
this form. Cannot add CAGE or Organization code(s) to account with
Multi-Site Uploader permission. The Nominating Official must have the
authority to permit the use of the CAGE Code(s) by Applicant.

32. Investigation Conducted By. Investigating agency.

16. Joint Clearance and Access Verification System (JCAVS). For
Government and Industry applicants.
16.a. Type of Account Requested. Select "Account Manager" only if
Applicant is to manage JCAVS accounts on behalf of the organization/
company/service.

34. Validating Official's Signature and Date. The Validating Official signature
serves to affirm the information provided on the following lines (verify before
signing): Eligibility/Access Level; Eligibility Granted Date; Eligibility Issued By;
Type of Investigation; Date Investigation Completed; and Investigation Conducted
By. For non-DoD government agency requests, the Chief of Security or designee
must complete this section.

16.b. Access Requested - Industry. Select appropriate permission(s).
16.c. Access Requested - Government Only. Select appropriate
permission(s).
16.d. Permissions Requested. Select appropriate permission(s).

Return completed forms to the appropriate Account Manager or the
DMDC Contact Center as outlined in the respective System Access
Request Procedures available from the DMDC PSA website.

DD FORM 2962v1 (INSTRUCTIONS), 20180920 DRAFT

33. Validating Official's Printed Name. Last Name, First Name, and Middle
Initial. If no middle initial, enter "NMN."