U.S.

Department of State

CRYPTOGRAPHIC ACCESS REQUEST

PART I - REQUEST FOR ISSUANCE OF CRYPTOGRAPHIC ACCESS
AUTHORIZATION (To Be Completed By All Employees)
To From (Name of Requesting Official, Title, and Office Symbol (if stateside) or Overseas Post (if overseas))

DT/EI/IM/CS/ES

Name of Employee (Last, First, MI) Date of Birth (mm-dd-yyyy) Employee Type
Full Time Employee
Contractor
SSN (Last Four of SSN Office Symbol/Overseas Post Grade Check if Applicable Expiration Date 1 Year
Full Time Required) From Date of Request
Employee - Locally Hired American (mm-yyyy)
Complete This Line EFM
Length of request of Crypto access. (mm/yyyy).
Full Time Maximum three (3) years or TED, whichever comes first.
Employee -
Complete This Line
SSN (Full SSN Required) Office Symbol/Overseas Post
Contractor -
Complete This Line

Is Cryptographic Access for TDY Travel? Yes No

If yes, From (mm-dd-yyyy) To (mm-dd-yyyy)

City Country

Job Title and Justification of Employee's Duties Which Require Cryptographic Access Authorization

PART II - CRYPTOGRAPHIC ACCESS AUTHORIZATION (To Be Completed By Contractors Only)

The named contract requires cryptographic access, the company holds an approved
DD-254 and a letter of consent has been issued.
COR Typed Name and Office Symbol Signature Date (mm-dd-yyyy)

Contract Number Task Number (If Any) Security Classification of Cryptographic Information to Existing Security Clearance
Which Employee will Require Access

Typed Name of Company Designated Representative Signature Date (mm-dd-yyyy)

Employed by is authorized to access cryptographic

Name of Employee Name of Company

information at the top secret level. He or she (is) (is not) authorized access to operational U.S. Government traffic information for installation,
maintenance or operation of cryptographic equipment for the government.

DS-3090 Page 1 of 2
11-2021
 PART III - BRIEFING CERTIFICATE (To Be Completed By All Employees)

A. I understand that I am being granted access to U.S. classified cryptographic information. I understand that my being granted access to this
information involves me in a position of special trust and confidence concerning matters of national security. I hereby acknowledge that I have been
briefed concerning my obligations with respect to such access.

B. I understand that safeguarding U.S. classified cryptographic information is of the utmost importance and that the loss or compromise of such
information could lead to irreparable damage to the United States and its allies. I understand that I am obligated to protect U.S. classified
cryptographic information and I have been instructed in the special nature of this information and the principle for the protection of such information.
I acknowledge that I have also been instructed in the rules requiring that I report any foreign contacts, visits, and travel to my appropriate security
officer and that, prior to this briefing, I reported any unauthorized foreign travel or foreign contacts I may have had in the past.

C. I understand fully the information presented at the briefing I have received, and I am aware that any willful disclosure of U.S. classified cryptographic
information to unauthorized persons may make me subject to prosecution under the criminal laws of the United States. I have read this certificate
and my questions, if any, have been answered. I acknowledge that the briefing officer has made available to me the provisions of Sections 641,
793, 794, 798, and 952 of Title 18 and Section 783 of Title 50 of the United States Code, and Executive Order 13526. I understand and accept that
unless I am released in writing by an authorized representative of my appropriate security office, the terms of this certificate and my obligation to
protect all U.S. classified cryptographic information to which I may access applies during the time of my access and at all times thereafter.

Typed Name of Administering Official Signature Date (mm-dd-yyyy)

Typed Name of Employee Signature Date (mm-dd-yyyy)

PART IV - DEBRIEFING CERTIFICATE (To Be Completed By All Employees)

I am aware that my authorization for access to U.S. classified cryptographic information is being withdrawn. I fully appreciate and understand that the
preservation of the security of this information is of vital importance to the welfare and defense of the United States. I certify that I will never divulge
any U.S. classified cryptographic information which I acquired, nor discuss with any person of the U.S. classified cryptographic information to which I
have had access, unless and until freed from this obligation by official written notice from competent authority. I affirm that I am familiar with the
provisions of sections 641, 793, 794, 798, 952, of Title 18, Section 783 of Tile 50 United States Code, and Executive Order 13526.
Typed Name of Administering Official Signature Date (mm-dd-yyyy)

Typed Name of Employee Signature Date (mm-dd-yyyy)

Privacy Act Statement

The information is sought pursuant to 5 U.S.C. § 301 (Management of Executive Department); 22 U.S.C. § 3921 (Management of
the Foreign Service); 22 U.S.C. § 2651a (Administration by the Department of State); and Executive Orders 11652 and 12968.
AUTHORITY Authority to solicit Social Security Number (SSN) derives from Executive Order 9397, as amended by Executive Order 13478
(November 18, 2008).

Purpose: The information solicited on this form is necessary to determine eligibility for a Department of State Cryptographic
PURPOSE Access. Social Security numbers are used to identify individuals seeking a Cryptographic Access.

Routine Uses: The information on this form may be shared with an individual's Contract Company. Providing this information,
ROUTINE USES including SSN, is voluntary, but your failure to do so will prevent access to U.S. classified cryptographic information.

DS-3090 Page 2 of 2