1092C Personnel Security Data Form-Contractor

PERSONNEL SECURITY DATA FORM
CONTRACTOR

OMB Control Number: XXXX-XXXX

National Credit Union Administration
Office of Continuity and Security Management

Section A: Applicant Information

Last Name (Legal Family)
Social Security Number

First Name (Legal Given)
Date of Birth MM/DD/YYYY

Middle (or NMN if none)

Place of Birth (City and State)

Other Names Used

Suffix

Country (non-U.S.)

Gender
M

Home Street Address (P.O. Box not accepted)

U.S Citizen?
Yes

F

Naturalized U.S. Citizen?
No

Yes

No

Non-U.S. citizens, see Instructions below
Email Address

Phone Number

Section B: Contract Information
Risk Level (Submit SOW to PERSEC if unknown)
Low

Moderate

Company Name (Prime)

Other NCUA Point of Contact

Company Name (Sub-Contractor)

Office/Region Supporting

Performance Manager (NCUA or Contractor)

High

Applicant will require (select all that apply):
IT Access

NCUA COR or Point of Contact

Facilities Access

What is the Applicant's physical working location?
Western
Southern
Eastern
Central Office
Field/Remote
Contract Number

Contractor Dates of Service (full contract length; see Instructions below)

INSTRUCTIONS
Use: This form, in its entirety, must be submitted for any contractor requiring access to NCUA information, systems, or facilities.
Submission: A typed document is preferred to avoid delays and incorrect information. The applicant's full legal name is required. All
documentation must be submitted by the COR to Personnel Security at [email protected].
Non-U.S. Citizens: If the applicant is a non-U.S.citizen, submit a copy of their foreign passport and work authorization documents along with
this form (i.e. permanent resident card).
Access: Contractor Dates of Service will be utilized to determine an end date for the applicant's services (i.e. termination of access).
Utilize the end of the contract including all option years, if another date has not been established.
Privacy Act: AUTHORITY: 5 CFR § 731 and 736; Executive Order 13467; Executive Order 12968/SEAD 4. Disclosure of the requested
information is not mandatory. PURPOSE: To assist NCUA personnel in making an informed decision regarding suitability for federal
employment, fitness for contract employment, and/or granting of a security clearance. ROUTINE USE(S): In addition to the disclosures
generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act, the information contained herein may specifically be used to document the
outcome of adjudicative determination for the issuance of the HSPD-12 PIV card or the local agency access badge, and to document the
outcome of adjudicative determinations for suitability, fitness, and/or national security clearances. Contact information is used for
communication and authentication purposes. A complete list of Routine Uses is available at NCUA-1, Personnel Access and Security
System (81 FR 12748). EFFECTS OF NOT PROVIDING INFORMATION: The requested information is needed to process your claim for
employment and/or access. Disclosure of your personal information is voluntary. However, failure to provide the requested information may
result in removal from the hiring process. SORN: NCUA-1, Personnel Access and Security System (81 FR 12748), Office of Personnel
Management OPM/Central-9.
Paperwork Reduction Act Statement: This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of
the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and
Budget (OMB) control number. The OMB control number for this collection is XXXX-XXXX. We estimate that it will take 10 minutes to read
the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for
reducing this burden, or any other aspects of this collection of information to: NCUA, Office of Continuity and Security Management,1775
Duke Street, Alexandria, VA 22314-3428.

NCUA 1092C

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