Form Exchange Form 3900 Exchange Form 3900 e-QIP Request Form

OMB NO. 0702-0135
OMB approval expires
MMM DD, YYYY

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

AGENCY DISCLOSURE NOTICE

PRIVACY ACT STATEMENT

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The public reporting burden for this collection of information, 0702-0135, is estimated to average 30 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 the burden estimate or burden reduction suggestions to the 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.

AF

AUTHORITY: 10 U.S.C. §7103, “Secretary of the Army”; 10 U.S.C. §9013, “Secretary of the Air Force”;
United States Presidential Executive Order (E.O.) 13526, “Classified National Security”; E.O. 10450, “Security
Requirements for Government Employment”; Department of Defense Instruction (DoDI) 5200.01, “DoD
Information Security Program and Protection of Sensitive Compartmental Information”; DoDI 5200.02, “DoD
Personnel Security Program (PSP)”; Army Regulation (AR) 380-67, “Personnel Security Program”; Air Force
Instruction (AFI) 31-501, “Personnel Security Program Management”; AFI 31-401, “Information Security
Program Management”; AR 215-8/AFI 34-211(I), “Army and Air Force Exchange Service Operations”; 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.

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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, State, Local, and Foreign Law Enforcement, Intelligence, or Security agencies in connection with
a lawful investigation under their jurisdiction.

D

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.

A copy of the Privacy Impact Assessment (PIA) for the collection of information may be located at https://www.aafes.com/aboutexchange/public-affairs/FOIA/assessments.htm
SYSTEM OF RECORD NOTICE (SORN): 1703.03, "Personnel Security Clearance Case Files"; https://dpcld.defense.gov/Privacy/
SORNsIndex/DOD-Component-Notices/Army-Article-List/

EXCHANGE FORM 3900-013

e-QIP REQUEST FORM

OMB NO. 0702-0135
OMB approval expires
JUN 30, 2019

(Electronic Questionaires for Investigations Processing)
Please type or write legibly

Instructions:
1. Before completing, please read the Disclosure Notice and the Privacy Act Statement on page one.
2. 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.

Ia. EXCHANGE/CONTRACTOR*
Choose One:

Exchange

Date of Request:

Contractor

(ex: 25 Jul 2015)

Ib. EXCHANGE/CONTRACTOR*
Choose All That Apply:

Remote

Sensitive

Non-Sensitive

II. APPLICANT'S INFORMATION*
(Full Name)

Last:

Gender:

Middle:

First:

Male
Female

Date of Birth:

Place of Birth:

Social Security #: (9 digits only)

(ex: 25 Jul 2015)

(City, State) or (City, Country, overseas only)

Region:

Work Location (Military Base/HQ Department):
Phone #:

Position Title:

Email Address:

Is job associated with ...? Choose all that apply:
Deployment

Childcare

Firearms

Other

Exchange Hire Date:

(ex: 25 Jul 2015)

III. PRIOR MILITARY/FEDERAL CONTRACTOR/FEDERAL AGENCY*
Choose One:

Provide Military/Federal Agency/Federal Contractor (within 24 months)
Yes
From: (Month/Year)
To: (Month/Year)

No

IV. EXCHANGE PERSONNEL ONLY*
Supervisor's Name:

Phone Number/Email:

(Extention #)

Human Resource Manager's Name

Phone Number/Email:

(Extention #)

V. EXCHANGE PERSON OF CONTACT (POC) - CONTRACTORS ONLY*
Exchange POC Name:

Phone #:

Facility # (8-10 Digits):

Contractor's POC Name:

Phone #:

Contract #/PO #:
Company's POC Email Address:

Contracting Company Name:

(City, State) or (City, Country, overseas only)

VI. REQUIRED DOCUMENTS*

Choose Type of Fingerprint Submission and include: Local Police Report and OF 306. Contractors must provide National Background Check.

Electronic Fingerprints Transmission Date:
Resume'/Application

OF 306

(ex: 25 Jul 2015)

Local Police Report

Fingerprint Card
(SF87 Rev. March 2013)

Fair Credit Reporting Disclosure and Authorization

National Background Check (Contractors Only)
FedEx this completed form with the hardcopy fingerprint card and police report to:
Exchange (EG-FP)
3911 S. Walton Walker Blvd.
Dallas, TX 75236-1598

VII. EXCHANGE EG-FP ONLY
Initiator/Reviewer/Approver:

Date: (dd/mmm/yyyy)

Status:

Initiator/Reviewer/Approver:

Date: (dd/mmm/yyyy)

Status:

Comments:
EXCHANGE FORM 3900-013 (JAN 19)

*(Request will not be processed without the required information and documents).