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Thomas Loomis 703-682-4912

Requestor’s Name and contact number __________________________________________
The following information is needed to create a profile to enable an individual
to complete a security questionnaire electronically via e-QIP.
Last Name

First Name

Middle Name

Full Social Security Number

Date of Birth (MM/DD/YYYY)

Place of Birth (city and state, if US; city and country if foreign)

E-Mail Address (if available) or a packet will be mailed to the mailing address
listed below

Job Title Technical Specialist

Assigned Office (i.e., Response, IT, CFO, Mitigation, etc.)

Public Assistance Division, PA TAC Contract # HSFEHQ-
Position Type (Permanent, CORE, DAE, Contractor)
Intern: (Paid/Unpaid) Duration ____________________________ Contractor
If you are a Federal Contractor provide:
Prime Contract Firm and Contract Number AECOM Recovery
- Contract No. HSFEHQ-12-D-0879
COTR’s name and telephone number: Eddie Murphy, COTR 202-646-2658

Position Sensitivity/Access Level (PT Moderate Risk; PT High Risk)

Public Trust/Moderate Risk
Has the United States Government ever investigated your If yes, provide the name of the Agency and the
background and/or granted you a security clearance? date the investigation was conducted.
Agency Date
Mailing Address

Telephone Number

Federal Employee Security packet will consist of 3 signature pages printed from e-QIP, a Declaration for Federal Employment (OF-306), a resume in OPM format or
preferably an OF-612 Application for Employment; a Fair Credit Reporting Act Release (FCRA); and (2) SF-87 fingerprint cards.

Federal Contractor Security packet will consist of 3 signature pages printed from e-QIP: a Fair Credit Reporting Act Release (FCRA); (2) FD-258 Applicant fingerprint
cards; and a DHS 11000-6 Non-Disclosure form.

WARNING: This document is FOR OFFICIAL USE ONLY (FOUO) and may contain PRIVACY SENSITIVE information. Any misuse or unauthorized access may result in
both civil and criminal penalties. It is to be controlled, stored, handled, transmitted, distributed, and disposed of in accordance with DHS policy relating to FOUO
information. This information shall not be distributed beyond the original addressees without prior authorization of the originator. This communication, along with
any attachments, is covered by Federal and State law governing electronic communications and may contain restricted and legally privileged information. If the
reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, use or copying of this message is strictly
prohibited. If you have received this in error, please reply immediately to the sender and delete this message.

Revised May 2010