BEP Background Information Request Form

Privacy Act Statement
Collection of this information is authorized by 31 U.S.C. section 321, and implementing Treasury and Bureau Regulations.
The information requested on this form will be used by the Bureau of Engraving and Printing’s security personnel to conduct
background investigations of companies and individuals seeking access to Federal Reserve notes and other Government
securities.
As set forth under the Bureau’s System of Records Notice No. Treasury/BEP .021, the information provided may be routinely used
to:
(1) Disclose pertinent information to appropriate Federal, State, local or foreign agencies responsible for
investigation or prosecuting the violations of, or for enforcing or implementing, a statute, rule, regulation,
order, or license, where the disclosing agency becomes aware of an indication of a violation or potential
violation of civil or criminal law or regulation;
(2) Disclose information to a Federal, State or local agency, maintaining civil, criminal or other relevant
enforcement information or other pertinent information, which has requested information relevant to or
necessary to the requesting agency’s or the bureau’s hiring or retention of an individual, or issuance of a
security clearance, license, contract, grant, or other benefit;
(3) Disclose information to a court, magistrate, or administrative tribunal in the course of presenting evidence,
including disclosures to opposing counsel or witnesses in the course of civil discovery, litigation, or
settlement negotiations, in response to a subpoena, or in connection with criminal law proceedings;
(4) Disclose information to foreign governments in accordance with formal or informal international
agreements;
(5) Provide information to a congressional office in response to an inquiry made at the request of the
individual to whom the record pertains;
(6) Provide information to the news media in accordance with guidelines contained in 28 CFR 50.2 which
relates to an agency’s functions relating to civil and criminal proceedings;
(7) Provide information to unions recognized as exclusive bargaining representatives under the Civil Service
Reform Act of 1978, 5 U.S.C 7111 and 7114, and
(8) Provide information to third parties during the course of an investigation to the extent necessary to obtain
information pertinent to the investigation.
(9) Appropriate agencies, entities, and persons when
(a) The Department suspects or has confirmed that the security or confidentiality of information
in the system of records has been compromised;
(b) The Department has determined that as a result of the suspected or confirmed compromise
there is a risk of harm to economic or property interests, identity theft or fraud, or harm to the
security or integrity of this system or other systems or programs (whether maintained by the
Department or another agency or entity) that rely upon the compromised information; and
(c) The disclosure made to such agencies, entities, and persons is reasonably necessary to assist
in connection with the Department’s efforts to respond to the suspected or confirmed
compromise and prevent, minimize, or remedy such harm.
Completing this form is voluntary. Failure, however, to provide all of the requested information may delay or prevent the Bureau
from conducting its background investigation, which may preclude you from obtaining access to the Federal Reserve notes or
other Government securities.

Bureau of Engraving and Printing Background Information Request Form
COMPANY INFORMATION
FULL NAME OF COMPANY: ___________________________________________________________
HEADQUARTERS PHONE NUMBER: ___________________________________________________
WEBSITE ADDRESS: __________________________________________________________________
EMAIL ADDRESS: _____________________________________________________________________
HEADQUARTERS PHYSICAL ADDRESS:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

HEADQUARTERS MAILING ADDRESS:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

ALL OTHER ADDRESSES ASSOCIATED WITH COMPANY:
(ALL ADDRESSES IN WHICH BUREAU OF ENGRAVING AND PRINTING SECURITES WILL BE
STORED/UTILIZED IN)
1. FACILITY NAME: __________________________________________________________________
PHYSICAL ADDRESS

MAILING ADDRESS

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

PHONE NUMBER: _____________________

2. FACILITY NAME: __________________________________________________________________
PHYSICAL ADDRESS

MAILING ADDRESS

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

PHONE NUMBER: _____________________
3. FACILITY NAME: ___________________________________________________________________
PHYSICAL ADDRESS

MAILING ADDRESS

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

PHONE NUMBER: _____________________

IF MORE THAN 3, ATTACH THE INFORMATION FOR ADDITIONAL LOCATIONS TO THIS FORM.
IS THIS COMPANY A PUBLIC TRADING COMPANY?

YES

NO

HAS THIS COMPANY TRADED/CONDUCTED BUSINESS UNDER ANY OTHER NAMES?
YES

NO

ARE THERE ANY SUBSIDIARIES OF THIS COMPANY?
YES

NO

IF YES, PLEASE NAME:
_______________________________________________________________________________________
_______________________________________________________________________________________

HAS THIS COMPANY EVER FILED FOR BANKRUPTCY?
YES

NO

IF YES, WHEN AND WHAT TYPE?
_______________________________________________________________________________________
_______________________________________________________________________________________

1. COMPANY EXECUTIVE
NAME

TITLE

(LAST, FIRST MIDDLE)

_______________________________________________________________________________________
DATE OF BIRTH

COUNTRY OF BIRTH

(MONTH/DAY/YEAR)

_______________________________________________________________________________________
SOCIAL SECURITY NUMBER

PASSPORT NUMBER

_______________________________________________________________________________________
HOME ADDRESS

BUSINESS ADDRESS

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

BUSINESS PHONE NUMBER: ___________________________________________________________
EMAIL ADDRESS: _____________________________________________________________________

2. COMPANY EXECUTIVE
NAME

TITLE

(LAST, FIRST MIDDLE)

_______________________________________________________________________________________
DATE OF BIRTH

COUNTRY OF BIRTH

(MONTH/DAY/YEAR)

_______________________________________________________________________________________

SOCIAL SECURITY NUMBER

PASSPORT NUMBER

_______________________________________________________________________________________
HOME ADDRESS

BUSINESS ADDRESS

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

BUSINESS PHONE NUMBER: ___________________________________________________________
EMAIL ADDRESS: _____________________________________________________________________

3. COMPANY EXECUTIVE
NAME

TITLE

(LAST, FIRST MIDDLE)

_______________________________________________________________________________________
DATE OF BIRTH

COUNTRY OF BIRTH

(MONTH/DAY/YEAR)

_______________________________________________________________________________________
SOCIAL SECURITY NUMBER

PASSPORT NUMBER

_______________________________________________________________________________________
HOME ADDRESS

BUSINESS ADDRESS

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

BUSINESS PHONE NUMBER: ___________________________________________________________

EMAIL ADDRESS: _____________________________________________________________________

COMPANY REPRESENTATIVE (PERSON RESPONSIBLE FOR NOTES)
NAME

TITLE

(LAST, FIRST MIDDLE)

_______________________________________________________________________________________
DATE OF BIRTH

COUNTRY OF BIRTH

(MONTH/DAY/YEAR)

_______________________________________________________________________________________
SOCIAL SECURITY NUMBER

PASSPORT NUMBER

_______________________________________________________________________________________
HOME ADDRESS

BUSINESS ADDRESS

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

BUSINESS PHONE NUMBER: ___________________________________________________________
EMAIL ADDRESS: _____________________________________________________________________

1. COMPANY DESIGNEE (PERSON WHO WILL BE HANDLING/TESTING THE NOTES)
NAME

TITLE

(LAST, FIRST MIDDLE)

_______________________________________________________________________________________
DATE OF BIRTH

COUNTRY OF BIRTH

(MONTH/DAY/YEAR)

_______________________________________________________________________________________
SOCIAL SECURITY NUMBER

PASSPORT NUMBER

_______________________________________________________________________________________
HOME ADDRESS

BUSINESS ADDRESS

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

BUSINESS PHONE NUMBER: ___________________________________________________________
EMAIL ADDRESS: _____________________________________________________________________

2. COMPANY DESIGNEE (PERSON WHO WILL BE HANDLING/TESTING THE NOTES)
NAME
TITLE
(LAST, FIRST MIDDLE)

_______________________________________________________________________________________
DATE OF BIRTH

COUNTRY OF BIRTH

(MONTH/DAY/YEAR)

_______________________________________________________________________________________
SOCIAL SECURITY NUMBER

PASSPORT NUMBER

_______________________________________________________________________________________
HOME ADDRESS

BUSINESS ADDRESS

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

BUSINESS PHONE NUMBER: ___________________________________________________________
EMAIL ADDRESS: _____________________________________________________________________

3. COMPANY DESIGNEE (PERSON WHO WILL BE HANDLING/TESTING THE NOTES)
NAME

TITLE

(LAST, FIRST MIDDLE)

_______________________________________________________________________________________

DATE OF BIRTH

COUNTRY OF BIRTH

(MONTH/DAY/YEAR)

_______________________________________________________________________________________
SOCIAL SECURITY NUMBER

PASSPORT NUMBER

_______________________________________________________________________________________
HOME ADDRESS

BUSINESS ADDRESS

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

BUSINESS PHONE NUMBER: ___________________________________________________________
EMAIL ADDRESS: _____________________________________________________________________

4. COMPANY DESIGNEE (PERSON WHO WILL BE HANDLING/TESTING THE NOTES)
NAME

TITLE

(LAST, FIRST MIDDLE)

_______________________________________________________________________________________
DATE OF BIRTH

COUNTRY OF BIRTH

(MONTH/DAY/YEAR)

_______________________________________________________________________________________
SOCIAL SECURITY NUMBER

PASSPORT NUMBER

_______________________________________________________________________________________
HOME ADDRESS

BUSINESS ADDRESS

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

BUSINESS PHONE NUMBER: ________________________________________________________

EMAIL ADDRESS: _____________________________________________________________________

Bureau of Engraving and Printing Physical Security Requirements
BEP Securities are considered sensitive Government property subject to full accountability. Authorized
personnel from the BEP may conduct an audit and/or on site security inspection at anytime. BEP Securities
are, and remain at all times the property of the United States Government.
The Company shall limit access to the BEP Securities to employees listed in the BEP Information Request
Form. All BEP Securities and any media containing images of the BEP Securities shall be secured in a
GSA Approved Class VI security container or equivalent in accordance with AA-F-358H (Federal
Specification for safes) when not being utilized for testing. Said containers shall be stored in an area under
controlled access which is monitored by closed circuit television (CCTV) within the Company. This area
may only be accessed by authorized personnel of the Company. The method of storage must prevent
access, use, distribution, or replication by unauthorized persons.
The alarm schematics and floor plans of the areas to be utilized for securing the BEP Securities in all
location(s) listed in the BEP Information Request Form, must be submitted with this request. These
will be maintained by the Product and Investigations Branch for purposes of evaluating the security of the
facility, to reference if a breach has been reported, and/or to assist in inspecting the facility.
A Sample Floor Plan is provided. The floor plans should be provided with a minimum level of detail
reflecting that of the Sample Floor Plan. Plans should be submitted to Norman Simms, Investigator,
Product and Investigations Branch, 14th and C Streets, SW, Room 744A, Washington, DC 20228; phone:
(202) 874-2295; fax (202) 874-0894. Alternatively, alarm schematics and floor plans may be submitted via
e-mail to: [email protected].

Sample
(One for each physical address)

SECURITY INFORMATION
The secure room (vault) at (Facility Name) is protected by the following systems/devices.
•
•
•
•
•
•

The building is protected by _______________________________system.
All entry and exit points are alarmed and or monitored by
____________________________________________________________.
Motion detectors have been placed
____________________________________________________________.
The secure room/vault entry is controlled by
____________________________________________________________.
The safe (if being utilized) is _____________________________________.
Any other pertinent information concerning security of the facility or rooms being utilized for BEP
Securities

FACILITY NAME

VAULT

LOCATION WITHIN FACILITY

CARD READER

VAULT

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