DOE F 473.2 Badge Request Electronic

OMB Control No. 1910-1800
Expires 10/31/2021
OMB Burden Disclosure
Statement on Reverse

U.S. DEPARTMENT OF ENERGY
SECURITY BADGE REQUEST

DOE F 473.2
(10/2021)

TO: Office of Headquarters Personnel Security Operations

(J) Date:

(A) FROM: NAME (printed) AND SIGNATURE OF DOE
SPONSOR HAVING LIAISON WITH APPLICANT

(K) U.S. CITIZEN?

(B) TITLE

DIVISION/OFFICE

I certify that the applicant requires access to a DOE HQS facility to
Conduct Official DOE business
(C) DOE Sponsor Telephone Number:
(D) NAME OF APPLICANT
(Last)

(First)

(Middle Name)

YES

NO

IF NO, COUNTRY

(L) REQUEST APPLICANT BE ISSUED:
DOE HEADQUARTERS SITE-SPECIFIC SECURITY BADGE (USED AT HQ ONLY)
(CHECK ONE):
“BAO” TO HQ Facilities
“FOREIGN NATIONAL”
DOE STANDARD SECURITY BADGE (Used at HQ AND Other DOE Sites):
(CHECK ONE):
Q
TS
L
S
BAO (Also Check):
IPA
OGA
(M) BADGE AT:
FORSTL
CONTRACT NUMBER:
CONTRACT EXPIRATION DATE:

GTN

(N) EMPLOYER CERTIFICATION
I certify that a DOE Security badge is required for the applicant to perform official duties in a DOE
facility. Pre-employment checks were conducted in accordance with company policy, all checks were
favorable, and the applicant was found to be suitable for employment

(E) SOCIAL SECURITY NUMBER

Printed Name and Signature

(F) APPLICANT’S EMPLOYER NAME (Company Name)

I concur that the applicant requires access to a DOE facility to perform official duties.

(G) EMPLOYER ADDRESS:

Printed Name and Signature of COR, Routing Symbol

Date

Date

I concur that the applicant requires access to a DOE facility to perform official duties

(H) EMPLOYER Telephone Number
Printed Name and Signature HSO (or Federal Designate), Routing Symbol

Date

(I) PRIME CONTRACTOR NAME:
PRIVACY ACT STATEMENT ON REVERSE
(A). (B), & C

DOE F 473.2 INSTRUCTIONS
FROM: NAME (printed) AND SIGNATURE, TITLE, DIVISION/OFFICE AND TELEPHONE NUMBER OF DOE SPONSOR HAVING LIASON WITH APPLICANT
Provide printed named and signature, title, office and telephone number of DOE Federal employee sponsoring and certifying applicants’ need for a
security badge.

(D) & (E)

APPLICANT’S NAME AND SOCIAL SECURITY NUMBER (SSN)
Applicant’s FULL NAME (Last, First and Middle) AND SSN.

(F), (G), & (H)

APPLICANT’S EMPLOYER NAME, ADDRESS & TELEPHONE NUMBER
Name, address, and telephone number of the company employing the applicant requiring a security badge.

(I)

PRIME CONTRACTOR NAME
Name of company listed as the Prime Contractor for the DOE Contract.

(J)

DATE
Date request is being submitted.

(K)

IS THE APPLICANT A U.S. CITIZEN
Check YES or NO. If NO, then indicate the country of citizenship.

(L)

INDICATE BADGE TYPE TO BE ISSUED
DOE HEADQUARTERS SITE-SPECIFIC SECURITY BADGES are issued to:
- Uncleared (Building Access Only – BAO) contractor employees or other personnel who perform work or require access ONLY at DOE HQ Facilities.
- Foreign Nationals
DOE STANDARD BADGES are issued to:
- Contractor, Other Government Agency (OGA), or Intergovernmental Personnel Act (IPA) employees with DOE HQS clearances.
- Uncleared BAO contractor, OGA, or IPA employees who require access to DOE HQS and other DOE Sites.
NOTE: If the applicant is an OGA or IPA employee, ALSO check the appropriate OGA or IPA box provided.

(M)

BADGE AT
Check where the applicant is to be badged; Forrestal or Germantown. The DOE F 473.2 must be forwarded to the appropriate badge office location.
CONTRACT NUMBER & EXPIRATION DATE
Provide the Contract Number and Expiration Date of the DOE Contract.

(N)

EMPLOYER CERTIFICATION
Designated person employed with the applicant’s company authorized to sign the certification.
CONTRACTING OFFICER REPRESENTATIVE (COR) & HEADQUARTERS SECURITY OFFICER (HSO) CONCURRENCES
Printed name/signature and date of the DOE Federal COR overseeing the contract. The printed name/signature and date of the HSO (or Federal
employee delegated in writing to sign for the HSO) supporting the DOE Federal Sponsor.

OMB Control No. 1910-1800
Expires 10/31/2021
OMB Burden Disclosure
Statement on Reverse

DOE F 473.2
(10/2021)

OMB BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time to exist data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. The collection of this information is mandatory to protect national security and
other critical assets entrusted to the Department. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to Office of Environment, Health, Safety and Security, U.S. Department of Energy, 1000 Independence Avenue, S.W., Washington,
D.C. 20585;S and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-1800), Washington, DC 20503.

Privacy Act Statement Contract/Consultant Badge Information Request
Collection of the information requested is authorized by the Atomic Energy Act of 1954, as amended, and by Executive Orders 13764, 10865, and 13526. The collection of
this information is mandatory to protect national security and other critical assets entrusted to the Department. Your name and Social Security Number are used as
identifying factors to establish and maintain records of DOE access authorization actions in the DOE System of Records, DOE-43, “Personnel Security Files,” and this form
will be completed and maintained in your DOE Personnel Security File. Individuals may access and correct their information in accordance with the Privacy Act of 1974, as
amended, 10 CFR Part 1008. Information in this record may be shared in accordance with routine uses listed in, DOE-43, “Personnel Security Files.”

FOR USE BY HEADQUARTERS OPERATIONS ONLY
SITE-SPECIFIC SECURITY BADGE
“ACCESS ONLY”

DOE STANDARD SECURITY BADGE
“FOREIGN NATIONAL”

Q

TS

L

S

UNCLEARED/ BAO

DOE NUMBER:
DATE:
CHECKED BY:

Headquarters Personnel Security Operations