Form SSF 3237 SSF 3237 Contractor Personnel Access Application

Form Approved: O.M.B. No. 1620-0002, Expiration Date: 01/31/2010

PLEASE READ THE FOLLOWING INSTRUCTIONS ON THE
REVERSE SIDE BEFORE COMPLETING THIS FORM

CONTRACTOR PERSONNEL ACCESS APPLICATION

SECTION A - TO BE COMPLETED BY THE USSS RESPONSIBLE OFFICE
1. NAME OF USSS RESPONSIBLE OFFICE

2. POINT OF CONTACT (Last, First, Middle)

4. SITE(S) TO BE ACCESSED BY CONTRACTOR

3. TELEPHONE NUMBER (with area code)

5. FREQUENCY OF ACCESS REQUIRED (circle one)

950 H STREET

TSD

BELTSVILLE

RDS

WFO

1111 18TH STREET

DAILY

6. POSITION TO BE HELD - OR - DUTIES TO BE PERFORMED

WEEKLY

MONTHLY

OTHER

7. LENGTH OF WORK TO BE PERFORMED

0 - 3 months

3 - 6 months

6 - 9 months

1 year

SECTION B - TO BE COMPLETED BY CONTRACTOR PERSONNEL
1. FULL NAME (last, first, middle)

2. MAIDEN NAME (if applicable)

3. OTHER ALIAS (last, first, middle)

4. SOCIAL SECURITY NUMBER

5. DATE OF BIRTH (month/day/year)

8. SEX

6. PLACE OF BIRTH (city, state, country)

WEIGHT

HEIGHT

HAIR COLOR

EYE COLOR

7. DRIVERS LICENSE NO. & STATE

9. RACE

Female
Male
10. PRESENT ADDRESS (street address, city, state, zip code)

Length of time at this address:

Hispanic or Latino

Asian

Native Hawaiian or other Pacific
Islander

Black or African American

White

11. TELEPHONE (area code, number)

work:
residence:
cellular:

years
months
12. MARITAL STATUS

American Indian or Alaskan Native

13. SPOUSE'S NAME AND ADDRESS (if applicable)

14. NAME AND ADDRESS OF EMPLOYER (company)

Length of time worked for this
employer:

15. NAME OF SUPERVISOR AND TELEPHONE NUMBER (with area code)

years
months
16. DO YOU HOLD U.S. CITIZENSHIP STATUS?
YES

(circle one)

NO

18, HAVE YOU EVER BEEN ARRESTED?
YES

(circle one)

NO

17. ARE YOU A NATURALIZED U.S. CITIZEN?

YES

(circle one)

NO

If yes, provide Naturalization date/alien no.:
If not a U.S. Citizen, provide alien registration no.:
19. HAVE YOU EVER BEEN CONVICTED OF ANY
CRIMINAL OFFENSE?
YES

(circle one)

20. ARE THERE ANY PENDING CHARGES AGAINST YOU
BEFORE ANY COURTS?

NO

YES

(circle one)

NO

NOTE: I understand than any false statement on any part of my application may be grounds for denying me access
into Secret Service controlled facilities, and/or grounds for prosecution under Title 18 USC 1001.
21. SIGNATURE OF CONTRACTOR PERSONNEL

22. DATE

RELEASE STATEMENT
This release when presented by a duly authorized representative of the U. S. Secret Service will constitute my consent and authority to obtain any
information relating to my activities from criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail businesses,
or other sources of information. The information may include my criminal history record information and financial and credit information.
Specifically, I hereby authorize the release of the following data or records to the U. S. Secret Service by applying my signature on the designated line
below.
Federal/State/Local Police & Criminal Records
(signature)
This authorization is given in connection with the investigative procedures being conducted relative to my contractual services with the U.S. Secret
Service, and/or access to secure areas occupied by the U.S. Secret Service.
Privacy Act Statement: All information requested on the Contractor Personnel Access Application and Release Statement is collected under authority derived from 18 USC
3056 and Executive Order 9397. The routine uses of information requested include referral to other Federal, State and Local agencies for determining suitability for access to
secure areas, and/or sensitive, unclassified material of the U.S. Secret Service. Submission of the information is voluntary, however, failure to provide information requested
may prohibit processing and cause denial of access to secure areas or sensitive material protected by the U.S. Secret Service. Disclosure of your Social Security Account
Number is voluntary. The information is used to identify and separate individuals with similar or identical names or initials. Refusal to disclose your Social Security Number
will be no cause for denial of any right, benefit or privilege provided by law.

UNITED STATES SECRET SERVICE

SSF 3237 (Rev. 08/2006)

Form Approved: O.M.B. No. 1620-0002

INSTRUCTIONS:
1. Please TYPE or PRINT clearly with a dark ball point pen.
2. To apply for access into U.S. Secret Service controlled facilities, Contractor Personnel must complete this form in
its entirety. (Failure to properly complete this form can result in contractual delays and/or non admittance into U.S.
Secret Service controlled facilities.
3. Fill out, sign and return to U.S. Secret Service, Security Clearance Division, Suite 3800, 950 H Street, NW,
Washington, DC 20223. (Must be completed and signed by individual person applying.)
4. If there are any questions regarding this form, please contact the Security Clearance Division at (202) 406-5830.

PUBLIC BURDEN INFORMATION

15 minutes per respondent or recordkeeper.
The estimated average burden associated with this collection of information is
Comments and or suggestions concerning the accuracy of this burden estimate and for reducing this burden should be directed to
the U.S. Secret Service, Management and Organization Division, Policy Analysis and Organizational Development Branch, Suite 7800,
950 H Street, NW, Washington, DC 20223; and to the Office of Management and Budget, Paperwork Reduction Project (1620-0002),
Washington, DC 20503. An agency may not conduct or sponsor, and a person is not required to, a collection of information unless
the collection of information displays a valid OMB control number.

UNITED STATES SECRET SERVICE

SSF 3237 (Rev. 08/2006)