AIAA STRATEGIC AND TACTICAL MISSILE SYSTEMS CONFERENCE
AIAA MISSILE SCIENCES CONFERENCE
(SECRET/U.S. ONLY)
24–26 January 2012
Naval Postgraduate School, Monterey, California
CLEARANCE CERTIFICATION FORM
Conference attendance requires U.S. Citizenship and at least a SECRET security clearance.
Applicant’s Name ____________________________________________________________________________
(Please print or type) Last First Middle
Name for Conference Badge ___________________________________________________________________
PERSONAL DATA (To be completed by applicant)
Social Security Number ____________________________________ Citizenship ________________________________________________
Place of Birth ____________________________________________ Date of Birth _______________________________________________
If you were not born in the United States, indicate how and where your U.S. citizenship was acquired.
Include Naturalization Certificate Number, if applicable.
Citizenship Acquired _______________________________________________ Where _________________________________________
Naturalization Certificate Number (if applicable) ___________________________________________________________________________
Affiliation ___________________________________________________________ Title ___________________________________________
Company, Military Activity, or Government Agency
Affiliation Address _____________________________________________________________________________________________________
Street City State Zip Code
Date ___________________________________________________ Signature _________________________________________________
NOTE – PENALTY FOR MISREPRESENTATION: Title 18 of the United States Code makes it a criminal offense, punishable by a maximum of 5 years
imprisonment, a $10,000 fine, or both, to make a false statement or representation to any department or agency of the United States. This includes any
statement knowingly made by an employer or employee herein that is found to be incorrect, incomplete, or misleading in any important particular.
SECURITY (To be completed by security official)
I certify that the applicant has a ______ TOP SECRET ______ SECRET security clearance.
Date ________________________________ Typed or Printed Name ______________________________________
Organization ______________________________________________________________________________________
FSC/CAGE Number ______________________________ Signature ________________________________________
Must be submitted by 19 December 2011 to:
JPAS SMO: 3F4085 SECURITY REQUIREMENTS
POC: (List “AIAA Conf” in the point of contact block in JPAS) Notes may not be taken during the conference sessions. Electronic devices,
POC Phone: 703.284.4280 including cell phones, radios, PDAs, laptops, cameras, video/audio recording
Fax: 703.284.5545 equipment, and two-way pagers, must be left in the hotel room as they will not
POC: Michael Vargo be allowed in the auditorium. One-way pagers must be placed on vibrate
POC Phone: 703.284.4280 during the conference sessions.
POC E-mail: michael.s.vargo@raytheon.com
Raytheon Company
AIAA Strategic/Tactical – Missile Sciences Conference 2012
1100 Wilson Blvd (Suite 1600 – Attn: Vargo)
Arlington, VA 22209
PHOTOGRAPHS ARE REQUIRED: Applicant’s name, organization, and photograph will be used by Raytheon to issue the conference badge.
Photo will be matched to security clearance information. Submit a JPEG digital photograph (from middle of chest to top of head), 300 dpi or greater,
2 x 2 inches or greater in size, to Raytheon via e-mail to michael.s.vargo@raytheon.com. Note: Label photo file as “last name, first initial.jpeg”.
Badges for all conference sessions will be issued at the AIAA registration desk at the Hyatt Regency Monterey on Monday, 23 January, 1500–1900
hrs and in King Hall at the Naval Postgraduate School on Tuesday, 24 January, 0700–1600 hrs, Wednesday, 25 January, 0700–1600 hrs, and
Thursday, 26 January, 0700–1300 hrs.
To confirm receipt of this form, contact michael.s.vargo@raytheon.com.
Note: You will be required to show photo identification for conference registration/badge issue
(State driver’s license, Military I.D. Card (DD Form 2) or company photo I.D.)
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