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Access Approval Authority AAA Government Only Access Disapproved 37. Remarks/Restrictions Classified by Derived from Declassify On CONTINUE ON SEPARATE SHEET IF NECESSARY per FSE dated 20050330 Program Access Request PAR November 20 2014 Previous Editions are Obsolete Privacy Sensitive when filled-in Any misuse or unauthorized disclosure may result in either civil or criminal penalties. Classify as Appropriate When Filled-in PROGRAM ACCESS REQUEST 1. Program Name 2. Access Level 4. Last Name First Name Middle Initial 5. Rank/Grade 8. Date of Birth YYMMDD 9. City/State/Country of Birth 3. Date Requested YYMMDD 6. U*S* Citizen Yes 11. SAP DD-254 / Consultant Agreement Military Civilian Contractor 12. Job Title 7. SSAN No Consultant Full Time Part Time From 14. Organization/Company Name To 16. Command/Facility/CAGE Code if any 17. PSQ Date 20. Date Granted YYMMDD 21. Investigation Type 23. Date Completed YYMMDD 24. Security Investigation Status Joint Personnel Adjudication System JPAS or Scattered Castles SC check In Progress Date Initiated/Submitted YYMMDD include additional information in the Remarks section below as needed Out-of-Scope Approval Date YYMMDD Current 26. Justification N/A 15. Assignment/Job Location City State 19. Granted By 18. Security Clearance Temporary Period of access 22. Conducted By Date Checked Acceptable JPAS results YYMMDD Acceptable Scattered Castles results Unacceptable JPAS results Unacceptable Scattered Castles results include detailed justification as to how this candidate will materially contribute to the program Continue on separate sheet if necessary CLASSIFICATION 27. Billet Number if any 28. Requestor Government/Contractor Mandatory Typed Name/Title/Organization Signature Telephone Number Date YYMMDD 29. SAP Personnel Security Official SPO Mandatory Eligible Needs Additional Review 30. Additional Coordination As Necessary Concur Non-Concur 32. Government SAP Security Officer/Contractor Program Security Officer GSSO/CPSO As Necessary 33. Government/Contractor Program Manager GPM/CPM As Necessary 34. Program Security Officer PSO Mandatory 35. SAP Central Office SAPCO Government Only As Necessary Approved Disapproved 36. Classify as Appropriate When Filled-in PROGRAM ACCESS REQUEST 1. Program Name 2. Access Level 4. Last Name First Name Middle Initial 5. Rank/Grade 8. Date of Birth YYMMDD 9. City/State/Country of Birth 3. Date Requested YYMMDD 6. U*S* Citizen Yes 11. Rank/Grade 8. Date of Birth YYMMDD 9. City/State/Country of Birth 3. Date Requested YYMMDD 6. U*S* Citizen Yes 11. SAP DD-254 / Consultant Agreement Military Civilian Contractor 12. Job Title 7. SSAN No Consultant Full Time Part Time From 14. SAP DD-254 / Consultant Agreement Military Civilian Contractor 12. Job Title 7. SSAN No Consultant Full Time Part Time From 14. Organization/Company Name To 16. Command/Facility/CAGE Code if any 17. PSQ Date 20. Date Granted YYMMDD 21. Organization/Company Name To 16. Command/Facility/CAGE Code if any 17. PSQ Date 20. Date Granted YYMMDD 21. Investigation Type 23. Date Completed YYMMDD 24. Security Investigation Status Joint Personnel Adjudication System JPAS or Scattered Castles SC check In Progress Date Initiated/Submitted YYMMDD include additional information in the Remarks section below as needed Out-of-Scope Approval Date YYMMDD Current 26.