FORM BC-1085 (5-16-2012)
U.S. DEPARTMENT OF COMMERCE
Economic and Statistics Administration
U.S. CENSUS BUREAU
POSITION SENSITIVITY LEVEL DESIGNATION
To be filled in by Applicant/Contractor
1.
Applicant/Contractor Full Name
2. Current Company Name and Address
SECTION B
DO NOT Email completed form
First
Middle Last
Street Address
City State ZIP code
Gender – Mark (X) one
4.
Female
Male
3. Current Position or Title
5. Other Government Agency you currently have clearance (if applicable)
6. Social Security Number
7. Daytime Telephone Number 8. Email Address
9.
Date of Birth 10. Place of Birth 11. US Citizenship – Mark (X) one
No – If no, complete SECTION B
Ye s
SECTION A
12.
Passport Number
13. Permanent Resident Card Number (If applicable)
15. Country of Current Residence14. Country of Citizenship (Dual, if applicable)
SECTION C
FOR COTR USE ONLY
Low Risk Moderate Risk Moderate Risk IT High Risk
17.
PIV Sponsor/COTR Signature
16. In performance of Contract No. the above reference applicant/contractor has
a position sensitivity level of:
18.
Date
Print or Type Name Signature
IndraSoft, Inc.
1768 Business Center Drive, Suite 200
Reston, VA 20190
