Date (mm-dd-yyyy)
PART IV - DEBRIEFING CERTIFICATE (To Be Completed By All Employees)
I am aware that my authorization for access to U.S. classified cryptographic information is being withdrawn. I fully appreciate and understand that the
preservation of the security of this information is of vital importance to the welfare and defense of the United States. I certify that I will never divulge
any U.S. classified cryptographic information which I acquired, nor discuss with any person of the U.S. classified cryptographic information to which I
have had access, unless and until freed from this obligation by official written notice from competent authority. I affirm that I am familiar with the
provisions of sections 641, 793, 794, 798, 952, of Title 18, Section 783 of Tile 50 United States Code, and Executive Order 13526.
Typed Name of Administering Official
Typed Name of Employee
DS-3090 Page 2 of 2
Privacy Act Statement
Authorities: The information is sought pursuant to 5 U.S.C. § 301 (Management of Executive Department); 22 U.S.C. § 3921 (Management of the
Foreign Service); 22 U.S.C. § 2651a (Administration by the Department of State), Executive Orders 11652 and 12968. Authority to solicit social security
number (ssn) is Executive Order 9397.
Purpose: The information solicited on this form is necessary to determine eligibility for a Department of State cryptographic access clearance. Social
Security numbers are used to identify individuals seeking a cryptographic access clearance.
Routine Use: The information on this form may be shared with an individual's contract company. Providing this information, including ssn, is voluntary,
but your failure to do so will prevent access to U.S. classified cryptographic information.
Typed Name of Employee
Typed Name of Administering Official
PART III - BRIEFING CERTIFICATE (To Be Completed By All Employees)
A. I understand that I am being granted access to U.S. classified cryptographic information. I understand that my being granted access to this
information involves me in a position of special trust and confidence concerning matters of national security. I hereby acknowledge that I have been
briefed concerning my obligations with respect to such access.
B. I understand that safeguarding U.S. classified cryptographic information is of the utmost importance and that the loss or compromise of such
information could lead to irreparable damage to the United States and its allies. I understand that I am obligated to protect U.S. classified
cryptographic information and I have been instructed in the special nature of this information and the principle for the protection of such information.
I acknowledge that I have also been instructed in the rules requiring that I report any foreign contacts, visits, and travel to my appropriate security
officer and that, prior to this briefing, I reported any unauthorized foreign travel or foreign contacts I may have had in the past.
C. I understand fully the information presented at the briefing I have received, and I am aware that any willful disclosure of U.S. classified cryptographic
information to unauthorized persons may make me subject to prosecution under the criminal laws of the United States. I have read this certificate
and my questions, if any, have been answered. I acknowledge that the briefing officer has made available to me the provisions of Sections 641,
793, 794, 798, and 952 of Title 18 and Section 783 of Title 50 of the United States Code, and Executive Order 13526. I understand and accept that
unless I am released in writing by an authorized representative of my appropriate security office, the terms of this certificate and my obligation to
protect all U.S. classified cryptographic information to which I may access applies during the time of my access and at all times thereafter.
Date (mm-dd-yyyy)
Date (mm-dd-yyyy)
Date (mm-dd-yyyy)
Signature
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