Fillable Personal Identity Verification (PIV) Request for DOE Security (Western Area Power Administration)

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Personal Identity Verification (PIV) Request for DOE Security (Western Area Power Administration)

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U.S.A. forms for Western Area Power Administration

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DOE F 206.3 PIV File Number: ______________________________
(2/2006) (for use by Registrar’s Office Only)
Personal Identity Verification (PIV) Request for DOE Security Badge
Privacy Notice: 42 U.S.C. 7101, 50 U.S.C 2401 and Public Law 93-579 permit collection of the data requested on this form. The information is used to determine
suitability for the issuance of a DOE security badge. The information will be used to identity proof and register Applicants as part of the Personal Identity Verification
process. Providing this information is voluntary; however, failure to submit this information may result in denial of a DOE security badge.
A. PIV Request & Source Document Confirmation (To be completed by Sponsor or Human Resources)
1. Type of DOE Security Badge? New Replacement 1a. Reason for Replacement: _____________________________________
2. BI* Application Complete? Yes (required for new DOE Security Badge) [* “BI” is a generic reference to all investigations]
No (Replacement badge) No (Prior BI) Agency: _____________________________ Case #, if available: ____________________
Applicant Information 3. Contractor Employee Federal Employee Sponsor Information
4. Full Name:_______________________________ 5. SSN: ____________________ 13. Name: ________________________________
6. DOB (mm/dd/yyyy): ___/___/______ POB: ______________________________ 14. Organization: ___________________________
7. Company Name: _____________________________________________________ 15. Phone: ________________________________
8. Company Address: ___________________________________________________ Fax: __________________________________
9. City: ______________________ 10. State: ___________ 11. Zip: _________ 16. E-mail: ________________________________
12. E-mail: _________________________________ Phone: ____________________
I agree to sponsor the above application for a PIV DOE Security Badge and certify that the information is accurate to the best of my knowledge.
17. Sponsor or Human Resources Signature: 18. Date (mm/dd/yyyy): ___/___/______
B. Identity Source Document 1 Identity Source Document 2
19. Name: _______________________________________________ 24. Name: _____________________________________________
20. Doc. #: _______________________________________________ 25. Doc. #: _____________________________________________
21. Doc Title: _____________________________________________ 26. Doc Title: ___________________________________________
22. Issuer: _______________________________________________ 27. Issuer: _____________________________________________
23. Doc Expiration Date (mm/dd/yyyy): _____/_____/______ 28. Doc. Expiration Date (mm/dd/yyyy): _____/_____/______
29. Citizenship: ____________________________
30. Document Title:__________________________________
I hereby verify that I have reviewed the above documents and that they are valid to the best of my knowledge.
31. Verifier Name (printed) & Signature: _________________________________________________ 32. Date (mm/dd/yyyy): ___/___/_____
C. Registrar Approval
FBI Fingerprint Check Results Registrar Information
33. Date Completed (mm/dd/yyyy): ____/____/______ 36. Name:_________________________________
34. Successful? Yes No 37. Organization: ___________________________
35. Comments:_________________________________________________________ 38. Phone: ________________________________
I hereby certify that the information regarding the above Applicant is accurate to the best of my knowledge and approve this application for a
DOE Security Badge issuance.
39. Registrar Signature: ________________________________________________________ 40. Date (mm/dd/yyyy): ___/___/_____
D. DOE Security Badge Issuance Issuer Information
41. Name on DOE Security Badge _________________________________________ 44. Name: ________________________________
42. DOE Security Badge Number: __________________________________________ 45. Organization: ___________________________
43. DOE Security Badge Expiration Date (mm/dd/yyyy) ____/____/______ 46. Phone: ________________________________
I hereby acknowledge issuance of a DOE Security Badge to the Applicant identified above based on verification of the Applicant’s identity and
verification of the above Registrar’s issuance approval.
47. Issuer Signature: ____________________________________________________________ 48. Date (mm/dd/yyyy) ___/___/_____
E. Applicant Acknowledgement (To be completed by Applicant, after Section D is completed)
I, the Applicant, confirm receipt of the DOE Security Badge identified above and that the information is accurate to the best of my knowledge.
49. Applicant Signature: __________________________________________________________ 50. Date (mm/dd/yyyy): ___/___/_____
F. Final Disposition
51. NACI Completion Date: ___________________ 52. NACI Identifier (Case #): ____________________ 53. Issues?: Yes No
54. Adjudication Date: ___________________ 55. Favorable Unfavorable
56. Registrar Name (printed) & Signature: ______________________________________________ 57. Date (mm/dd/yyyy): ___/___/______
Revocation of DOE Security Badge
(if unfavorable adjudication):
58. Revoking Authority Name (printed) & Signature: ________________________________________ 59. Date: (mm/dd/yyyy): ___/___/_____
DOE F 206.3
(2/2006) Instructions for Completing the PIV Request Form
Section A
1. Check appropriate box to indicate if this is a new or
replacement DOE Security Badge. If “Replacement” is
selected, complete item 1a.
1.a. If applicable, enter reason a replacement DOE
Security Badge is needed.
2. Select “Yes
” if an SF-85 or SF-86 form is attached.
Select “No (Replacement badge)
” if “Replacement”
was selected in Item 1.
Select “No (Prior BI)
” if an acceptable prior back-
ground investigation is known to exist. Provide the
name of the agency (source) and the associated case
number (case #) in the space provided, if known.
3. Check appropriate box to indicate whether Applicant is
a Federal or contractor employee.
4. Enter Applicant’s full legal name.
5. Enter Applicant’s social security number.
6. Enter Applicant’s date of birth and place of birth.
Include country if foreign born.
7. Enter name of employer.
8. Enter mailing address of employer listed in item 7.
9.-11. Enter city, state, and zip code portion of employer’s
mailing address.
12. Enter Applicant’s home or work electronic mail
(e-mail) address and phone number.
13.-16. Enter name, program office, work Phone & Fax
numbers, and e-mail address of DOE Federal employee or
authorized M&O contractor having direct liaison with
Applicant.
17.-18. Signature and date of signature of the Federal
Sponsor or Human resources representative (Federal or
contractor) completing the form.
Section B
All information entered in Section B is identified as
pertaining to the Applicant listed in Section A, item 4.
19. Enter Applicant’s name as identified on first I-9
source document. (Document must be presented in person
and in original form.)
20. Enter unique identification number associated with
document listed in item 19.
21. Enter title or name of document listed in item 19.
22. Enter name of agency, agent, or entity issuing
document listed in item 19.
23. Enter, if applicable, the expiration date of the
document listed in item 19.
24.-28. Complete for the second I-9 document in the same
manner as listed for the first in items 19.-23.
29. Enter country of Applicant’s current citizenship.
30. Enter title of document used to prove Applicant’s
citizenship.
31.-32. Signature, printed name, and date of the individual
reviewing and validating the identity source documents
presented in person and in original form.
Section C
33. Enter date fingerprint check results were received
from Office of Personnel Management (OPM)
34. Indicate, by checking the appropriate box, the
fingerprint check results.
35. Enter any comment(s). (Optional)
36.-38. Enter name, program office, and work phone
number of Registrar.
39. -40. Registrar’s signature and date of signature.
Section D
41. Enter Applicant’s name as printed on DOE security
badge.
42. Enter unique DOE Security badge serial number
associated with this badge.
43. Enter expiration date of the DOE security badge being
issued to Applicant at this time.
44.-46. Enter name, employing office, and work phone
number of person issuing this DOE security badge.
47.-48. Issuer’s signature and date of signature.
Section E
49.-50. Applicant’s signature and date of signature.
Section F
51. Enter date that OPM completed/closed the NACI.
52. Indicate OPM’s case number for the NACI.
53. Indicate, by checking the appropriate box, whether the
NACI transmittal reflects the presence of issues
(derogatory information) requiring further adjudication.
54. Enter date NACI was reviewed for adjudication.
55. Select whether adjudication of NACI was favorable or
unfavorable by checking the appropriate box.
56.-57. Registrar’s printed name, signature, and date of
signature after performing the adjudication.
58.-59. If revocation is required
: Revoking Authority’s
signature, printed name, and the date the DOE Security
Badge is revoked.
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Personal Identity Verification (PIV) Request for DOE Security (Western Area Power Administration)

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Completed 19 July 2020

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