Get documents about "UCN-21519 Badge Request Form
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Y-12 National Security Complex PRIME CONTRACT NUMBER (B&W Y-12, WSI OR OTHER PRIME TO NNSA)
SUBCONTRACT NUMBER: EFFECTIVE DATE: EXPIRATION DATE:
BADGE REQUEST FORM
BADGE EFFECTIVE DATE: BADGE EXPIRATION DATE:
BADGE EFFECTIVE DATE should coincide with date employee will require Y-12 access.
SPECIAL UPDATE ONLY BADGE EXPIRATION DATE should coincide with date employee will no longer need
access to the Y-12 complex or the current expiration date of contract.
EMPLOYER SECURITY BRIEFING
CONTRACTOR JOB TITLE
(LEGAL NAME OF EMPLOYER THAT PAYS APPLICANTS WAGE) DATE:
FEDERAL-YSO
COUNTRY OF
NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH PLACE OF BIRTH
CITIZENSHIP
SOCIAL SECURITY
APPLICANT‟S HOME ADDRESS & PHONE # APPLICANT‟S E-MAIL ADDRESS
NUMBER:
PURPOSE
The purpose of this data collection is in accordance with DOE N 206.4 regarding identity-proofing procedures
CLEARANCE INFORMATION
CLEARANCE REQUIRED? YES NO
ACCESS REQUIREMENTS
Is EA/PA/MAA access needed? YES NO If yes, attach UCN-2847 (orange card) for permanent access request.
Note: If Uncleared or L-cleared, submit an escort agreement request (UCN-17629) to Physical Security for EA and PA approval.
BADGING DEPARTMENT USE
Badge Number: ______________________
DOE Clearance level: U L Q Date granted: _____________________
Reason: New Hire Re-badge Clearance Change
Briefings needed: Initial Comprehensive 30 day transfer Previous K____________
Proof of Citizenship: Attached On file New K____________
Badge Type: LT LSSO-L LSSO-Q HSPD-12 (reissue) NNSA – NO “C”
Emergency Response Official (ERO) Stripe Required YES
Applicant (Print Name) (Applicant will sign when receiving badge) Signature Date
CERTIFICATION
I certify that the LSSO Badge is being requested/certified in accordance with DOE N 206.4
Requesting Official (Name/Badge number/Signature/Date/Employer /Phone number) Signature Date
No.:
Organization/Address: Phone No.:
Badging Official/Issuer:
/Signature: /Date:
This request will be kept on file for 90 days after which time a new request must be resubmitted if badging is still required.
Sponsor: E-mail scanned completed form to „Ybadging‟ or Fax completed form to Y-12 Badge Office @ 241-8932
When completed, this form contains Privacy Act Information- protect accordingly
UCN-21519 (02-10)
Y-12 National Security Complex Badge Request Form Instructions
Note: Effective March 1, 2010, all submitted clearance requests, except reinvestigations, must be submitted with UCN-22307, “DOE
Security Clearance Questionnaire For Y-12 NSC,” and UCN-21519, “Y-12 National Security Complex Badge Request Form.”
Reinvestigation requests must include a completed UCN-22307, “DOE Security Clearance Questionnaire For Y-12 NSC.”
The Y-12 National Security Complex Badge Request Form (i.e., UCN-21519) is required when requesting a photo badge for a person
who will be working at the Y-12 National Security Complex. A sponsor representing Y-12 or a contractor to Y-12 must submit the
completed form. The information on this form will be protected from unauthorized disclosure. The Privacy Act of 1974, as amended,
governs the collection, maintenance, and disclosure of this information.
Follow the instructions fully. The form should be completed electronically, printed, and signed. The form may be scanned and sent
via e-mail to ybadging@y12.doe.gov, faxed to 865-241-8932 (Badge Office), or hand-carried to the Y-12 Visitor Center, New Hope
Center, 602 Scarboro Road, Oak Ridge, TN 37831. Illegible or incomplete forms will be returned.
Prime Contract Number: Provide the prime contract number under which the applicant will work.
Subcontractor Number: Required if work is being performed under a subcontract to the prime contractor. Enter
the subcontract number, ROS, P.O., etc.
Effective Date: The date the contract begins.
Expiration Date: The date the contract ends.
Badge Effective Date: The date the individual will first require access.
Badge Expiration Date: The date the badge will expire. This date may coincide with the contract end or may
reflect the date the individual will no longer work on the listed contract, or a shorter period determined by the
Badge Office.
Special Update Only: May be used to notify the Badge Office of a contract extension or change of the applicant
from one contract to another contract with the same company.
Contactor: Check if the applicant is a contractor employee.
Federal-YSO: Check if the applicant is a federal employee.
Employer: Full legal name of the employer. The applicant must be employed by, and paid by, this employer.
Job Title: Brief title of the position where applicant will be assigned.
Security Briefing Date: Date individual is scheduled to attend a Security Briefing.
Name: Full last, first, and middle name as reflected on identification documents. Do not use nicknames.
Date of Birthday: Date applicant was born.
Place of Birth: City and state or city and country of birth.
Country of Citizenship: Country where applicant holds citizenship.
Social Security Number: Social Security Number of applicant.
Applicant’s Home Address & Phone: List street mailing address and home or cell telephone number.
Applicant’s E-mail Address: List a work or home e-mail address used regularly by applicant. May be used for
notifications to applicant that must be read timely.
Clearance Information: Check whether the individual will require a security clearance.
Access Requirement: For Q-cleared applicants, check whether Exclusion Area/Protected Area/Material Access
Area access is needed; if “yes” is checked, attach orange card.
Badging Department Use: For Badge Office use only.
Applicant: Applicant will sign and date when he/she receives badge.
Requesting Official: Requesting Official name and signature.
Badging Official/Issuer: For Badge Office use.
When completed, this form contains Privacy Act Information- protect accordingly
UCN-21519 (02-10)
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