1. Name (Last, First, MI)
U.S. Department of State
CONTRACTOR COUNTRY CLEARANCE REQUEST (CCCR)
DS-7677
09-2011
I. TRAVELER INFORMATION
2. Traveler's Place of Birth (State or Country, if not U.S.)
3. Passport Number 4. Passport Type 5. Country of Passport Issuance
6. Employer - Name of Contracting Company
II. EMPLOYER INFORMATION
7. Name of Contracting Company POC or FSO
9. E-Mail of Contracting Company POC or FSO8. Phone Number of Contracting Company POC or FSO
10. Name of DoS COR or POC 11. Office/Bureau of DoS COR or POC
III. TRAVEL INFORMATION
12. Contract Number under which this Travel is Authorized 13. Clearance Level (if applicable)
14. Destination Post/Site 15. Travel Date - Arrival (mm-dd-yyyy) 16. Travel Date - Departure (mm-dd-yyyy)
17. Purpose of Visit
IV. INFORMATION FOR POST
18. Name and Title of Post Sponsor or DoS Site POC 19. Access to PCC Required?
Yes No
20. Electronic Equipment to be brought onto Post/Site
ACRONYMS
CCCR
COR
DoS
DS
DS/IS/IND
FSO
MRPT
Contractor Country Clearance Request
Contracting Officer's Representative
Department of State
Diplomatic Security
Industrial Security Division
Facility Security Officer
Moderate Risk Public Trust
PCC
POC
RSO
SCI
SSM
SSO
VAR
Post Communications Center
Point of Contact
Regional Security Officer
Sensitive Compartmented Information
Site Security Manager
Special Security Office
Visit Authorization Request
PRIVACY ACT STATEMENT
Authorities The information solicited on this form is requested pursuant to applicable provisions of 22 USC 3927and 22 USC 4802.
Purpose The purpose for soliciting the information is to provide the Bureau of Diplomatic Security's Industrial Security Division (DS/IS/IND) with the
minimum data required to positively establish the identity of the traveler for security clearance verification and travel eligibility purposes.
Routine Uses/Disclosure The information solicited on this form may be disclosed pursuant to a court order or to law enforcement officials in the
conduct of authorized investigations.
Information requested is voluntary but failure to provide the information requested on this form may result in the denial or delay of the requested country
clearance.
INSTRUCTIONS AND PURPOSE:
CONTRACTOR COUNTRY CLEARANCE REQUEST (CCCR)
SUBMISSION INSTRUCTIONS
General
Form may be filled out by contractor traveler, or by contractor's FSO or Project Manager. Print or type information neatly.
If the traveler will visit more than one Post/Project Site, a separate CCCR must be submitted.
Section II
7. - 9. List name and e-mail of contracting company POC. If you have a clearance, this should be your FSO. If you do not have a clearance, list your
program manager.
10. - 11. List name and bureau of DoS COR or project/task manager. Examples of Bureaus: DS (Diplomatic Security), OBO (Overseas Building
Operation), CA (Consular Affairs), IRM (Information Management Bureau).
Section III
13. Specify Level of Clearance by selecting from the drop list. (Choices: None, Interim MRPT, MRPT, Interim Secret, Secret, Interim Top Secret, Top
Secret)
Section IV
18. List name and title of Post Sponsor or Site POC. Examples of Titles: Facility Manager, Information Management Officer, Consular Affairs Officer,
Site Security Manager, Project Director or Project Manager.
Submission
Completed form should be submitted via e-mail to DoS COR or DoS Project/Task Manager and to DS/IS/IND at INDeCCcerts@state.gov .
COR or DoS Project/Task Manager will convey approval or disapproval of travel to requestor and DS/IS/IND. If the COR does not approve/disapprove
travel within 2 business days, DS/IS/IND will seek approval/disapproval on the requestor's behalf.
If access to the PCC is required, DS/IS/IND will coordinate approval with the CSB TelClear entity.
DS/IS/IND will send a Contractor Travel Notification e-mail to appropriate entities at Post/Site (RSO, SSM, Post/Site Sponsor) with a courtesy copy to
the COR or DoS Project/Task Manager and the contractor requestor.
CCCRs will be processed by DS/IS/IND within 2 business days whenever possible. Submission of incomplete or incorrect forms, and coordination with
and receipt of approval for travel from COR or DoS Project/Task Manager, may require more than 2 business days.
PURPOSE OF THIS FORM
This form is to be used by DoS contractors (an individual employed by a firm under contract to DoS to perform services for DoS - sometimes referred to
as "third party contractors") only. This form will be used to notify overseas DoS diplomatic facilities or project sites of the contractor's intention to visit or
deploy to the overseas facility or site in conjunction with official contract business for DoS. This form should not be utilized for notification of personal
travel, and may only be used by DoS contractors. Contractors under contract to other Agencies must arrange for travel notification through that
Agency.
Submission of this form will result in official notification to RSOs, SSMs, and Post Sponsors (when applicable) of dates of visit (Note 1 and 2), purpose
of visit, all Posts/Project Sites to be visited during dates provided, security clearances level (or Public Trust Investigation data - Note 3), whether PCC
access is required, passport information and any electronic equipment the traveler intends to bring onto Post/Project Site (Note 4).
This form should not be sent directly to Post/Project Site by the contractor. RSO/SSM will not accept information from any entity other than DS/IS/IND,
who is responsible for processing of VARs, maintenance of the database for all contractor clearances, and certification of contractor clearance levels for
all contractors who will either perform at, or visit DoS locations.
Note 1 - Contractor travel notifications do not convey flight arrival/departure information. Itineraries should be provided by the traveler/contracting firm
directly to Post Sponsor or Site POC if requested by Post/Site.
Note 2 - Lodging, meet and greet, and transportation requests cannot be accomplished via CCCRs. Any Post/Project Site assistance should be
coordinated separately with the Post Sponsor, Project Site POC, or by the COR.
Note 3 - SCI indoctrination status cannot be passed via CCCR. If SCI status info is required for travel to Post, contractor should contact DS SSO.
Note 4 - Listing electronic equipment on the CCCR does not constitute approval or permission to bring items onto Post or Site. Approval to bring
electronic items on Post/Project Site should be coordinated separately with Post Sponsor or SSM.
DS-7677
09-2011
Instruction Page
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