REQUEST FOR PERSONNEL SECURITY ACTION

1 E6 REQUEST FOR PERSONNEL SECURITY ACTIONAUTHORITY: 10 8012; 44 3101; and EO PURPOSES: To identify investigation, SECURITY clearance, unescorted entry requirements, and special access program USES: To REQUEST PERSONNEL SECURITY investigations, record emergency or limited access authorization, entry to restricted areas, and to recordspecial access program authorizations. SSN is used for positive identification of the individual and IS VOLUNTARY: Failure to information and SSN could result in assignment to less sensitive NAME(Last, First, Middle, Maiden)2. ORGANIZATION OR FIRM GRADE4. SSNUS CITIZENIMMIGRANT ALIENON-US NATIONAL6. DATE OF BIRTH7. PLACE OF BIRTH (City, State, and Country) , CLEARANCE, ELIGIBILITY, ENTRY AND ACCESS , ENTRY OR ACCESS REQUIREMENTNATIONAL AGENCY CHECK (NAC)ONE-TIME ACCESSLIMITED ACCESSNATIONAL AGENCY CHECK-WRITTEN INQUIRIES (NACI)INTERIM CLEARANCESPECIAL ACCESSBACKGROUND INVESTIGATION (BI)FINAL CLEARANCEUNESCORTED ENTRYSPECIAL BACKGROUND INVESTIGATION (SBI)TOP SECRETPRIORITY BI PERIODIC REINVESTIGATION (PR)SECRETPRIORITY BSBI PERIODIC REINVESTIGATION (PR)CONFIDENTIALPRIORITY FILES CHECK10.

2 TO:11. FROM:12. DATE13. TYPED NAME, GRADE AND TITLE OF REQUESTER14. RECORDS CHECK15. I CERTIFY a medical records check required by DOD 205-32, has been completed and no information exists, unless shown in Section VII,which would preclude the granting of a SECURITY clearance, unescorted entry to restricted areas, or access to special program classified TYPED NAME AND GRADE OF BASE DIRECTOR, MEDICAL SERVICES16. DATE18. POLICE RECORDS CHECK19. I CERTIFY a SECURITY police records check required by AFR 205-32, has been completed and no information exists, unless shown in Section VII, whichwould preclude the granting of a SECURITY clearance, unescorted entry to restricted areas, or access to special program classified SIGNATURE20. DATE21. TYPED NAME AND GRADE OF SECURITY POLICE AUTHORIZATIONONE-TIME ACCESSLIMITED CERTIFY the named individual requires access to the above special program(s), meets all investigative and clearance requirements, and has been briefedon program responsibilities as outlined in the governing directive.

3 If applicable, emergency or limited access is necessary and will not endanger the SIGNATURE24. DATE25. TYPED NAME, GRADE AND TITLE OF APPROVING AUTHORITY29. SIGNATURE28. TYPED NAME, GRADE AND TITLE OF SPECIAL ACCESS PROGRAMCERTIFYING OFFICIAL27. (If more space is needed, use reverse and show item number being continued)PREVIOUS EDITION WILL BE IMT 2583, 19870301, V3