OMB No. 1670-0013
Expiration Date: 06/30/2018
DEPARTMENT OF HOMELAND SECURITY
CYBERSECURITY AND INFRASTRUCTURE SECURITY AGENCY
PRIVATE SECTOR CLEARANCE REQUEST FORM
**Please complete the form with the exception of the nominee's SSN, Date of Birth, and Place of Birth.
The nominee will be contacted directly by a DHS Security Specialist for this information.
FULL LEGAL NAME (First, Middle, Last, Suffix):
TYPE OF SUBMISSION:
COMPANY NAME AND ADDRESS:
WORK EMAIL ADDRESS:
WORK PHONE NO:
PERSONAL EMAIL ADDRESS:
NOMINEE IS CURRENTLY A MEMBER OF:
NOMINEE'S JOB TITLE/POSITION: (Do not use acronyms)
Has the Chief Security Officer or Facility Security Officer of the company been notified of the nomination?
Phone or e-mail:
Please provide CSO/FSO contact information. Name:
Is there a secure facility within 50 miles where a clearance holder may attend a classified briefing?
DD254 on File?
No, but I'm willing to travel
Nominee satisfied the following criteria (from EO 13549 Section 5.g):
Corporate owners and operators determined by the Secretary of Homeland Security to be part of the Critical Infrastructure;
Subject matter experts selected to assist with Federal or State Critical Infrastructure Security and Resilience;
Personnel serving in specific leadership positions of Critical Infrastructure coordination, operations, and oversight;
Employees of corporate entities relating to the protection of Critical Infrastructure;
Other persons not otherwise eligible for the granting of a personnel security clearance pursuant to Executive Order 12829, as amended, who
are determined by the Secretary of Homeland Security to require a personnel security clearance.
Nominee's positions require coordination with the Department of Homeland Security and the sharing of classified information regarding threats
to and protection of the nation's critical infrastructure involving the
Attach justification to the DHS Form 9014. Please see justification requirements in the instructions.
*Provide all of the below requested information ONLY if you previously held an active clearance within the last 24 months.
currently holds a
Top Secret clearance
Sponsored by (Name of Agency):
Contact Information of Security Official/Office:
will retire/separate from:
Date of retirement/separation:
NO (Check “yes” ONLY if you have a current clearance
or if your prior security clearance was active within
the last 2 years)
For Periodic Reinvestigations contact PSCP Administrator for number of times a clearance had been passed in last 24 months.
ASSISTANT DIRECTOR FOR ISD / CSD
DO NOT COMPLETE BELOW THIS LINE
DATE OF BIRTH:
PLACE OF BIRTH:
SOCIAL SECURITY NUMBER:
MAILING ADDRESS (optional):
DHS Form 9014 (2/18)
Page 1 of 3
Paperwork Burden Notice: The public reporting burden for this form is estimated to be 10 minutes. The burden estimate includes time for reviewing
instructions, researching existing data sources, gathering and maintaining the needed data, and completing and submitting the form. Your response
is voluntary. You are not required to respond to this collection of information unless a valid OMB control number is displayed. Send comments
regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to DHS/
CISA/PSCP, Mail Stop 0609, 245 Murray Lane SW, Bldg 410, Washington DC 20598. ATTN: PRA (1670-0013)
NOTE: DO NOT send your completed form to this address.
Privacy Act Statement:
Authority: Section 201 of the Homeland Security Act and Executive Orders 9397, 12968, 13526, and 13549 authorize the collection of this
Purpose: The primary purpose of this collection is to facilitate the background investigations required to potentially grant a security clearance to an
individual partner, serving as a subject matter expert within a specific industry and possessing knowledge not available within DHS. DHS will
maintain the roster of program members for contact purposes and to facilitate information sharing.
Routine Uses: Information will be shared with the Office of Personnel Management to conduct background investigations, as necessary and
authorized by the routine uses published in DHS/ALL-023 - Department of Homeland Security Personnel Security Management, 74 FR 3084
(January 16, 2009). Contact information may be shared with other Federal partners as necessary and authorized by the routine uses published in
DHS/ALL-002 - Department of Homeland Security Mailing and Other Lists System, 73 FR 71659 (November 25, 2008).
Disclosure: Participation in the program is voluntary; however, failure to provide this information may prevent the individual from participating in the
program or receiving a security clearance.
INSTRUCTIONS FOR WRITING THE JUSTIFICATION FOR THE NOMINEE
The nominator shall thoroughly complete the DHS Form 9014. Completion by the nominee is prohibited.
• Retrieve the nominee’s information during the vetting and interviewing process, and complete the DHS Form 9014.
• Interview the nominee's FSO/CSO to ensure the nominee meets the criteria and has a need-to-know.
If multiple nominees are submitted, each nominee will need an individual justification written up and a separate form submitted.
• Do not use a justification template when submitting justifications.
• Each nominee's justification should be tailored to their mission within DHS and the Sector.
1. Determine if the nominee is a Subject Matter Expert (SME) that has been selected to assist the Federal or State Critical
Infrastructure (CI) mission and is in a leadership or executive level position that can capitalize on the value of the classified
information being shared.
• Verify that a DHS or a federal entity, Sector Specific Agency (SSA), or Sector representative requested the nominee’s expertise
and intends to share classified information with the individual.
2. Determine the Federal requirements that need to be met for the nominee to be granted access to classified information as it relates
3. Define which Federal mission activity or Federal Office will be directly engaged with the nominee.
4. Describe the nominee’s need-to-know in detail.
5. Describe how the nominee will effectively utilize the classified information that is intended to be shared.
• It must involve a DHS related mission – not a company specific mission.
6. Define the frequency and location where the nominee will access classified information.
• What are the approved facilities where the nominee is expected to access classified information?
ż Note: Access to classified information at private sector locations are only authorized for entities that have a facility.
• Who in DHS, FBI or State Fusion Center will be sharing classified information with the nominee?
• Nominators must also validate with the identified Federal entities if they have a requirement and intention to share classified
information with the nominee. (Access to classified information is dependent on an existing Federal relationship. If there is no
defined Federal requirement, the nominee should not be submitted).
7. Provide a statement of CI work the nominee will be associated with in their assigned Sector.
8. Contact the SSA as necessary to validate the Sector’s requirements for providing classified access and to determine if the nominee
is a member of a Sector Coordinating Council (SCC) or Information Sharing and Analysis Center (ISAC).
• Access is not based solely on position or who the nominee knows.
• A nominee’s duty description, affiliations or accolades are not sufficient to support a justification.
DHS Form 9014 (2/18)
Page 2 of 3
INSTRUCTIONS FOR COMPLETING DHS FORM 9014
FULL NAME: Enter nominee's FULL legal name (First, Middle, Last, Suffix).
TYPE OF SUBMISSION: Select the reason for the form submission. Mark as an Initial Submission, Company Change, Reciprocity,
Reinstatement, or a Periodic Reinvestigation.
PROGRAM TYPE: Select the type of program the clearance is being requested under.
COMPANY NAME/ADDRESS: Enter nominee's company name and address where they receive their business mail.
WORK EMAIL ADDRESS: Enter the nominee's work email address.
WORK PHONE: Enter the nominee's 10-digit work phone number.
PERSONAL EMAIL ADDRESS: Enter a personal email address for the nominee (such as a yahoo or gmail account).
MEMBER OF: Enter relevant National Infrastructure Protection Plan Framework Counsel membership.
CLEARANCE LEVEL: Select requested clearance level from the drop down list. The level of access granted shall not exceed the
Secret level, unless the sponsoring agency determines on a case-by-case basis that the applicant has a demonstrated and foreseeable
need for access to Top Secret, Special Access Program, or Sensitive Compartmented Information
NOMINEE'S JOB TITLE/POSITION: Enter the nominee's job title/responsibilities.
U.S. CITIZEN: The nominee must be a U.S. citizen to process for a DHS Security Clearance. Security clearances cannot be issued to
non-U.S. citizens. Please do not submit forms for non-U.S. citizens.
CHIEF SECURITY OFFICER (CSO): If appropriate, identify if the company CSO (or the Executive otherwise responsible for the
organization's security posture) has been notified of the request. Provide their name and work phone or official
e-mail address. There must be a name of higher authority in this section or "self". Do not leave blank.
SECURE FACILITY: Identify proximity of secure facility or ability to travel for classified briefing
EXECUTIVE ORDER (EO) CRITERIA: Select the criteria that most defines the nominee's role/responsibility within their company that
relates to the DHS Critical Infrastructure (CI) mission.
SECTOR: Select the nominee's sector affiliation
JUSTIFICATION: Include the justification for the nominee with the DHS Form 9014. For guidance, see the Instructions for Writing the
PRIOR/CURRENT CLEARANCE INFORMATION SECTION: Please indicate whether the nominee previously held/currently holds a
clearance, their level of clearance, and the Agency sponsoring the clearance. Please indicate the nominee's separation date from the
Agency sponsoring their clearance and provide a point of contact in that Agency's security office and their contact information.
RECIPROCITY/REINSTATEMENT: Check “yes” ONLY if the nominee has a current clearance or if their prior security clearance was
active within the last 2 years.
NOMINATOR: The authorized Federal Employee who is requesting the clearance and confirming the applicant's “need-to-know”. The
nominator will sign and date.
ASSISTANT DIRECTOR FOR ISD or CSD: The Assistant Director for Infrastructure Security Division (ISD) or Cybersecurity Division
(CSD) will either concur or non-concur with the request from the nominator. The Assistant Director will sign and date.
** DATE OF BIRTH / PLACE OF BIRTH / SOCIAL SECURITY NUMBER: LEAVE BLANK. The nominee will be contacted directly by a
DHS Security Specialist after you have been approved for security clearance processing.
** MAILING ADDRESS (Optional): LEAVE BLANK. There will be an option for the DHS Security Specialist to collect an alternate
mailing address if the nominee prefers finger print cards to be mailed to an address other than their company address.
THE NOMINATOR MUST COMPLETE THIS FORM
The Federal nominator should email the completed form to the DHS Security Specialist for processing.
DHS Form 9014 (2/18)
Page 3 of 3
|File Title||DHS Form 9014|
|Subject||PRIVATE SECTOR CLEARANCE PROGRAM,.COOPERATIVE RESEARCH AND DEVELOPMENT AGREEMENT, and.CLASSIFIED CRITICAL INFRASTRUCTURE PROTECT|