National Defense University Nomination for National Agen

CUI (when filled in)

NATIONAL DEFENSE UNIVERSITY
NOMINATION FOR NATIONAL AGENCY CHECK W/INQUIRIES FORM

O.M.B. Control No.
Expires:

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, [Insert OMB Control Number], is estimated to average 10 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mcalex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to
any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

SECTION I – REQUESTOR INFORMATION (To be completed by Requestor)
1. Name (Last, First, Middle)

2. Social Security Number

3. Date of Birth (MM-DD-YYYY)

4. Place of Birth (City/State)

5. Rank/Title

6. Branch of Service/Agency

7. Phone No. (Primary) ________________________

8. Citizenship

Cell

Home

Work

US

Phone No. (Secondary) _________________________
Cell
Home
9. Supervisor Name

FN _____________________

OTHER

Work

10. School/Component Assigned

First: _______________

Last: ___________________

Eisenhower

Title/Rank: ___________

Phone No. ______________

OTHER _______________

11a. Primary EMAIL Address

NWC
JFSC

11b. Secondary EMAIL Address

I understand that the information I have provided is voluntary. However, if the data is not provided, then NDU security system of records maintained by the Security
Department may not be accurate and or prevent you being initiated for a background investigation.

12. Respondent Signature

13. Date (MM-DD-YYYY)

SECTION II – SECURITY MANAGER INVESTIGATION REQUEST
14. Type of Investigation Requested

(To be completed by Security Office)

16. Fingerprints Completion Date

17. Investigation Completion Date

18. Initiated By

19. Date (MM-DD-YYYY)

15. Investigation Initiated Date

NOTICE: AUTHORITY: 10 U.S.C. 2163, 2165, Executive Order 9397, and Public Law 104-134 (soliciting SSN). PURPOSE: To record
names, identifiers, and SSN for the purpose to authenticate, track personnel records, create security records, initiate background investigations.
NOTE: Records may be maintained in both electronic and/or paper form. DISCLOSURE: Disclosure of this information is voluntary; however,
failure to provide the requested information may impede, delay or prevent further processing of this request.

CUI (when filled in)

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CUI (when filled in)

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 2165, National Defense University; 10 U.S.C. 2163
Degree Granting Authority for National Defense University and E.O. 9397, as
amended (SSN).
SOCIAL SECURITY ACCOUNT NUMBER (SSAN): Your SSAN is needed to
keep records accurate because other people may have the same name and birth date.
Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is
responsible for informing you whether disclosure is mandatory or voluntary, by what
statutory or other authority your SSAN is solicited, and what uses will be made of it.
Executive Order 9397 also asks Federal agencies to use this number to help identify
individuals in agency records.
PURPOSE: The data provided will be used to update your National Defense
University (NDU) record. NDU data are used to authenticate and identify NDU
personnel and students; complete background investigation, track academic
enrollment, assignments, progress, and assessments; track personnel records and
actions; create academic transcripts and related reports; facilitate award of degrees
and credentials; conduct analysis for regional and DoD academic accreditations; and
create reports for University leadership to aid in the development of effective
curricula, facilitate academic completion requirements.
ROUTINE USES: Data are shared with other Federal/State agencies and contractors
for the purpose of communicating educational credentials and accrediting University
programs. For a complete list of routine uses and authorities see the applicable system
of records notice, National Defense University (NDU) Student Data Files
(September 21, 2010, 75 FR 57458). The notice is located at:
https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-ArticleView/Article/570570/dndu01/
DISCLOSURE: Voluntary. However, if data in NDU systems are not up-to-date, your
NDU entitlements/privileges and the ability of NDU systems to identify you as an
NDU-affiliated person could be delayed or inaccurate. The production of accurate
academic transcripts may not be possible. Home addresses will be used for mustering
in the event of an officially declared manmade or natural disaster (DoDI 3001.02) and
for notification of a Privacy compromise, loss or stolen (breached) personally
identifiable information (PII). If addresses are not correct these two requirements will
not be performed with accuracy as to your location.

CUI (when filled in)

Controlled by:
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LDC:
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