FORM Modifications

DHS FORM 9014 MODIFICATIONS

STATE, LOCAL, TRIBAL AND PRIVATE SECTOR
CLEARANCE REQUEST FORM

July 2020

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DHS FORM 9014 MODIFICATION
Drop Down:
Company Change
Initial Submission
Reciprocity
Periodic Reinvestigation
Reinstatement
Upgrade
Downgrade

Drop Down:
CCIPP
CISCA
NSTAC
Private Sector
State and Local
Tribal

PERSONAL EMAIL ADDRESS
WORK EMAIL ADDRESS
Fillable
Box Only

CISCA Number

Drop Down:
Chemical
Commercial Facilities – Entertainment and Media
Commercial Facilities – Gaming
Commercial Facilities – Lodging
Commercial Facilities – Outdoor Events
Commercial Facilities – Public Assembly
Commercial Facilities – Real Estate
Commercial Facilities – Retail
Commercial Facilities – Sports Leagues
Communications
Dams
Defense Industrial base
Emergency Services
Energy Electric
Energy-Oil and Gas
Faith Based Outreach
Financial Services
Food and Agriculture
Government Facilities – Education Facilities
Government Facilities – Election Infrastructure
Government Facilities – National Monuments/Icons
Healthcare and Public Health
Information Technology
National Infrastructure Advisory Council (NIAC)
Non-Profit Organization
National Security Telecommunications Advisory Committee
Nuclear Reactors, Material and Waste
Transportation Systems – Aviation
Transportation Systems – Hwy Motor Carrier
Transportation Systems – Maritime
Transportation Systems Trans – Pipeline
Transportation Systems – Postal and Shipping
Transportation Systems – Public Transit
Transportation Systems – Rail
Water and Wastewater Systems

July 2020

ADD: ,EO 13691, Sec. 4(c), “Promoting Private Sector Cybersecurity
Information Sharing” and 32 CFR, Part 117, Sec. 117.22, National Industrial
Security Program Operating Manual (NISPOM))

Attach Justification Button

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DHS FORM 9014 MODIFICATION

Delete
Section

PERSONAL EMAIL ADDRESS

nominee has

WORK EMAIL ADDRESS
SLTPS

past 2 years).
to attend a classified briefing.

Drop Down:
CISA SRMA
Non-CISA SRMA
Non-DHS SRMA
PSA
RSOC
Sector Liaison
Chief Chemical Security Inspector
Supervisor Chemical Security Inspector
Chemical Inspector
Cybersecurity Advisor
Other [Fillable Box]

SIGNATURE AUTHORITY:

Delete
Section

Drop Down
Regional Director
Deputy Regional Director
Executive Assistant Director
Assistant Director
Deputy/EAD/AD
Other [Fillable Box]

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