APPLICATION FOR SECURITY CLEARANCE AND ACCESS CARD

Please complete the form below by using typed letters or CAPITAL LETTERS. Follow further instructions on the second page.

Part 1 is to be completed by the person who shall render service to or work for Norges Bank

PART
1

1.1 Name (For-, Middle- and Surname)

1.2 Date of Birth (dd/mm/yyyy)

Honnashree Premkumar

21/05/1982

1.3 Current Full Home Address (Country included)

1.4 Any Swedish or Danish SSN/ID No.

#21, A Sector, Opp Muneshwara temple, Amruthnagar,

Bangalore - 560092

1.6 Email address

1.7 Tel. No.(incl. country code)

honnashree.premkumar@cognizant.com

9008531950

1.5 Citizenship

INDIAN

1.8 Employer (Company Name if supplier)

Cognizant Technology Solutions

1.9 Do you have a national security clearance or NATO security clearance that
is not older than 3 years?
YES
NO
1.10 Countries of residence where you have lived for more than 1 year during the past 10 years, specifying the period of time (dd/mm/yyyy)
Country 1
From
Until

India

Country 2

From

Until

Country 3

From

Until

Part 2 is to be completed by NBIM Chief Security Officer (CSO) or person authorized by CSO
2.1 Operational area/Department

2.3 Type of badge

Permanent employee

ITI

PART
2

2.2.1 Contact

2.2.2 Manager

Karstein Holen

Daniel Bjorkman

Temporary employee
Retired
Supplier

2.4 Will the person have access to funds or information that can be exploited
for personal financial gain for the person himself or to others?
YES
(If YES, Security Management will obtain credit information of the person)
2.5 If access card is needed, please specify access level(s) and period of validity (dd/mm/yyyy)
Access level
From

Until

2.6 Date

NBIM Chief Security Officer (CSO) or person authorized by CSO

Part 3 is to be completed by Security Management (SIB)

3.1 Type of vetting

PART
3

Security
Clearence
Access
card

Approved type 1
Approved type 2
Exemption
Not applicable

3.2 Valid from date - until date (exemption)

3.3 Date granted

3.4 Decision-maker (position, name)

3.5 Badge No.

3.6 Handed out (date, name)

KF SIB 17.09.2012 (1.1) NBIM

Side 1 av 2

NO

All persons rendering services to, or working for, Norges Bank, or working for a supplier of services to the Bank, shall
be required to submit a police certificate of good conduct if security considerations so indicate, as stated in the Norges
Bank Act Section 11 Paragraph 4. It may also be commenced credit checks on reasonable grounds and verification of
academic records, certificates and previous employments.
INSTRUCTIONS PART 1:
1

2
3

The person who shall render service to, or work for Norges Bank, complete Part 1of the form and send it ASAP to
the contact in Norges Bank, preferably by email or together with any contract you may have signed. Email address
for employees of Norges Bank/NBIM: onboarding@nbim.no. Contractors from a vendor who has an account
manager serving Norges Bank: Send the form via the account manager.
Persons with Swedish or Danish Social Security Number/ID Number, must provide the last 4 digits to allow direct
search in Swedish and Danish credit information registries (on reasonable grounds).
Shortly after receiving this document, Norges Bank will commence a background check, which may include:
- Police certificate of good conduct
- Credit check
- Verification of academic records, certificates and previous employments
- Search in open sources (Internet)
You will receive applicable forms from Norges Bank.
Follow the instructions in the form(s) you receive, and complete these.

Main rules for police certificates:

- All persons rendering services to, or working for, Norges Bank, or working for a supplier of services to the
Bank, shall be required to submit a police certificate of good conduct if security considerations so indicate.
- Police certificate must be obtained from each country were lived for more than one (1) year during the last ten
(10) years.
- The Police certificate must be in original and not more than three (3) months old.
- Personnel, who serve periodically for Norges Bank (temporary employees and contractors form vendors), but
not for the last twelve (12) months, are required to present a new police certificate before a new assignment
can take place.
Personnel, who are citizens of another country than Norway, must obtain a police certificate from the country of
citizenship if resident there after the age of 18.

INSTRUCTIONS PART 2:
This part is to be completed by NBIM Chief Security Officer (CSO) or the person authorized by CSO when:
1.
2.
3.

Initial work/render service for the bank.

Changes in position or changes in the use of supplier personnel change the conditions mentioned in the form's
fields 2.4.
Changes in access level.

In case 2 and 3 when part 1 of the form is not completed, field 1.1 of the form is still mandatory.
In case 1 and 2, send the completed form to KF SIB Personkontroll (personkontroll@norges-bank.no).
In case 3, send the completed form to KF SIB Hovedvakten (hovedvakten@norges-bank.no).

INSTRUCTIONS PART 3:
This part is to be completed by Security Management (SIB)

KF SIB 17.09.2012 (1.1) NBIM

Side 2 av 2