BPA F 5632_09 Personal Identity Verification (PIV) Request

BPA F 5632.09e
(08-18)
Instructions

U.S. DEPARTMENT OF ENERGY
BONNEVILLE POWER ADMINISTRATION

OMB

PERSONAL IDENTITY VERIFICATION (PIV) REQUEST
Information Sheet for Sponsorship of DOE Security Badge or LSSO

Instructions for using the PIV Request/Information Sheet for Sponsorship of DOE Security Badge or LSSO
NOTE: All fields on the form are required. Incomplete forms will be returned for completion or correction. Processing
will be terminated if no action is taken or communication received from the applicant within 14 calendar days of PIV
process initiation.
Section A – Applicant Data
1. Enter Applicant’s full legal name (Last, First, Middle). If
no middle name, write (NMN). If applicant has an initial
only, write (IO). Abbreviated names are not accepted.
This is the name that will appear on the HSPD-12
credential (DOE Security Badge). Name must match
the identification presented at the time of enrollment or
PIV appointment.
2. Applicant’s email address. Applicant must have or
establish an email address for PIV processing.
3. Mailing address where applicant will be receiving mail
throughout the PIV process. Address must include
complete city, state, and zip code.
4. Applicant’s date of birth.
5. Phone number to best reach applicant throughout PIV
processing.
6. City, State, and Country where applicant was born.
7. Is applicant a U.S. citizen? If No, write country of
citizenship.
8. Is applicant a dual citizen? If Yes, write country of dual
citizenship.
9. Applicant’s social security number.
10. Has applicant previously been issued a BPA security
badge?
11. Has applicant ever been issued a Smart Credential by
BPA or other Federal agency? If Yes, list agency.
12. Is applicant a current or previous Federal Employee,
Federal Contractor, or Military with less than 24 months
break in Federal Service? Check “Yes” or
“No.” If selecting “Yes,” documentation such as a
Leave and Earning Statement (LES), Personnel Action
(SF 50), or Certificate of Release or Discharge from
Active Duty (DD214) from applicant must be included
when submitting PIV Request. Documentation is
required to verify that break in Federal Service is less
than 24 months.

15. Title of position applicant is being considered for.
16. Organization code applicant is to be assigned to.
17. Name of BPA Manager who will oversee applicant’s
performance.
18. What will be the applicant’s duty station? Check appropriate
box or “Other” and write duty station.
19. Will applicant require access to ASHE Substation or DOE
Headquarters (Germantown)? If yes, list sites where access
will be needed.
20. For Federal applicant positions, list the type of investigation
required (as determined by the Position Designation Tool).
Note: Include Contractor applicants when an investigation
for Public Trust is required.
21. Level of sensitivity for position applicant is being considered
for (applies only to federal applicants).
22. Nature of Action for position applicant is being considered
for (applies only to federal applicants).
23. Name of contracted company applicant is working for
(applies only to contractor applicants).
24. Address of contracted company applicant is working for
(applies only to contractor applicants).
25. Phone number of contracted company applicant is working
for (applies only to contractor applicants).
Section D – HR Representative/COTR Contact Info
26. Date HR Representative/COTR submitted PIV/Credential
Request.
27. Name of applicant’s HR Representative/COTR.
28. Routing information of applicant’s HR
Representative/COTR.
29. Phone number of applicant’s HR Representative/COTR.
30. Name of Request contact or alternate POC if applicable.
31. Routing information of contact or alternate POC.
32. Phone number of contact or alternate POC.

Section B – Credential Processing Data
13. Select Employment Type. Check appropriate boxes to
indicate all that apply to applicant.
14. Choose type of access applicant will need in the
performance of assigned duties. Note: Project Wise
access does not include access to BPA’s computer
network. If a Project Wise applicant requires additional
Physical & Logical access, please check all applicable
boxes.

SUBMITTING INSTRUCTIONS: PIV Request forms are to be mailed to the BPA PERSEC Registrar at mail-stop NNP-B1.

NOTE: This form contains Personally Identifiable Information (PII) and must be handled in accordance with
DOE Directives on PII.

BPA F 5632.09e

OMB

U.S. DEPARTMENT OF ENERGY
BONNEVILLE POWER ADMINISTRATION

(08-18)

PERSONAL IDENTITY VERIFICATION (PIV) REQUEST
Information Sheet for Sponsorship of DOE Security Badge or LSSO
Privacy Act Statement:
Authority: 42 U.S.C. 7101, et seq. and 50 U.S.C. 2401, et seq., 5 U.S.C. 552a, Homeland Security Presidential Directive 12.
Purpose: BPA will use this information to identity proof and register applicants and determine the suitability of issuance of a DOE security badge.
Routine Uses: We do not disclose your information to third parties without your consent, except to fulfill the purpose for collection or as legally required.
Records may be disclosed to: BPA employees and contractors as required to complete job duties; to necessary parties if the security or confidentiality of the
information in the records is compromised; and to the Department of Energy and other agencies to investigate potential violations of law, and as necessary
to minimize harm when information security has been compromised. Additional disclosures are listed in DOE-63 and GSA/GOVT-7.
Disclosure: Providing information on this form is voluntary. However, failure to provide the information requested may result in the denial of a security
badge.

All fields are required

A. APPLICANT DATA
1. Full LEGAL Name (Last, First, Middle, Suffix) (Name must match identification):

2. Email Address:

N/A
4. Date of Birth (mm/dd/yyyy):

3. Complete Mailing Address:

6. Place of Birth (City, State, Country):

7. U.S. Citizen?
If No, list country

Yes

✔

No

8. Dual Citizen?
Yes
No
If Yes, list country

5. Daytime Phone:

9. Social Security
Number:

10. Has the applicant previously been issued a DOE/BPA security badge? ✔ Yes
No
11. Has the applicant ever been issued a security badge or smart credential by another Federal Agency?
Yes
No
If yes, list agency:
12. Is the applicant a current or previous Federal Employee, Contractor, or Military with less than 24 months break in Federal Service?
Yes
No
If Yes, submit verifying documentation with this form (see instruction page for examples of acceptable documents).

B. CREDENTIAL PROCESSING DATA (Sections B & C to be completed by HR Representative/COTR)
13. Employment Type (Check all that apply):
Federal
Contractor

New
Converting
Returning

14. Type of Access Required for Position:

Apprentice/Student
Volunteer
Detail
Transfer

Project Wise / Physical Access
(NO BADGE Issued; Project Wise obtained through IT)

Physical Access
(with BPA LSSO Badge Issued)

Physical & Logical Access
(with DOE Security Badge Issued)

15. APPLICANT Position Title:
18. APPLICANT Duty Station:

16. APPLICANT Org Code:

BPA HQ

ROSS

Van Mall

17. APPLICANT Manager’s Name:

Other

19. Will applicant require access to other BPA/DOE sites during the performance of duties?
Yes

No

If Yes, lists sites:

All Federal Applicants. Include Contractor Applicants when an investigation for Public Trust is required.
20. Type of Investigation:

21. Sensitivity Level Code (Feds Only):

22. Nature of Action Code (Feds Only):

All Contractor Applicants Only
23. Contract Company Name:

24. Contract Company Address:

25. Company Phone:

C. HR REPRESENTATIVE /COTR CONTACT INFORMATION
26. Date Request Submitted:

27. HR Representative/COTR Name:

30. Request Contact Name (if applicable):

28. Routing:

29. Phone or Extension:

31. Routing:

32. Phone or Extension:

OFFICIAL USE ONLY
Contains information which may be exempt from public release under the
Freedom of Information Act (5 U.S.C. 552), exemption number 6 Personal Privacy.
Approval by the DOE/BPA prior to public release is required.

Name/Org: ____________________________________Date:________________

File Code; SS-18-12
RETENTION: Retain while Active* + 5 years,
and then dispose. *Active period ends upon

OMB

BPA F 5632.09e
(08-18)

Paperwork Reduction Act Burden Disclosure Statement
This data is being collected to ensure the security and safety of BPA employees, contractors, and facilities. The data you supply will be used by BPA
Security to register applicants and initiate the PIV process for issuance of a DOE security badge. Public reporting burden for this collection of
information is estimated to average .30 hours per response, including the time for reviewing instructions, searching exiting data sources,
gathering and maintaining that 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 this burden, to Office of the Chief Information
Officer, Enterprise Policy Development & Implementation Office, IM-22, Paperwork Reduction Project (enter OMB control number), U.S. Department
of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction
Project (enter OMB control number), Washington, DC 20503.

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to
comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays
a currently valid OMB control number.
The Paperwork Reduction Act (PRA) of 1995 requires each Federal agency to seek and obtain approval from the Office of Management and Budget
(OMB) before undertaking a collection of information directed to 10 or more persons of the general public, including persons involved in or supporting
the operations of Government-owned, contractor-operated facilities.