BPA F 1400.22a

(09-15)	U.S. DEPARTMENT OF ENERGY

BONNEVILLE POWER ADMINISTRATION
OTHER UTILITY/CONTRACTOR/VENDOR WORKER ACCESS REQUEST	Electronic Form Approved by Forms Mgmt. 09/03/2015
Privacy Act Statement:

Authority: 42 U.S.C. 7101, et seq. and 50 U.S.C. 2401, et seq., 5 U.S.C. 552a, Homeland Security Presidential Directive 12.

Purpose: BPA will use this information to identity proof and register applicants and determine the suitability of issuance of a DOE security badge.
Routine Uses: We do not disclose your information to third parties without your consent, except to fulfill the purpose for collection or as legally required. The information requested on this form is used by BPA to document compliance with NERC CIP Standards, which requires that personnel having authorized cyber or authorized unescorted physical access to BPA’s Critical Cyber Assets, including contractors and service vendors, have an appropriate level of personnel risk assessment, training, and security awareness. Records may be disclosed to: BPA employees and contractors as required to complete job duties; to necessary parties if the security or confidentiality of the information in the records is compromised; and to the Department of Energy and other agencies to investigate potential violations of law, and as necessary to minimize harm when information security has been compromised. Additional disclosures are listed in DOE-63 and GSA/GOVT-7.

Disclosure: Providing information on this form is voluntary. However, failure to provide the information requested herein will result in the denial of a security badge for the individual’s physical or cyber access to certain BPA information and/or facilities.
Other Utility/Contractors/Vendors will not be permitted limited BPA unescorted access without the completion of a background check, required compliance training and providing a photo for identification and badging purposes.

Other Utility Worker/Contractor/Vendor Companies are required to submit this completed form to: CSReliabilityProgram@bpa.gov

BPA’s TPC Office will send this form to Non-Government Employee Processing and Card Key Access. For recertification, please complete process again.
1. Other Utility/Contractor/Vendor completes
Check one: Initial Request	Re-Certification
Legal Name of Other Utility Worker/Contractor/Vendor (Last, First, Middle Initial)
Position Title	Company Name	Company Street Address (ID Badge to be sent to)	Company Phone Number	Company FAX Number
List of facilities needing access to:	Will you require 24-hour access?
Yes	No
Has Other Utility/Contractor/Vendor Successfully Passed National Criminal History Check?	Has Other Utility/Contractor/Vendor completed Annual Training? (Includes Security and CIPS overview)
Yes	No	If yes, Date Completed	Yes	No	If yes, Date Completed
Has Other Utility/Contractor/Vendor Successfully Completed Personal Identity Verification (PIV) Yes	No	if yes, Date Completed
Other Utility/Contractor/Vendor/Worker Photo attached to the form submittal Yes	No
I hereby certify that the information provided regarding the Other Utility Worker/Contractor/Vendor is accurate and documentation to support this information will be retained by Other Utility Worker/Contractor/Vendor employer and provide upon BPA’s request.
Required Signature - Manager from Other Utility/Contractor/Vendor Company
Name (Print or Type)	Signature of Manager from Other Utility/Contractor/Vendor Company	E-mail Address	Date
File Code;SS-18-12 Retention; See Agency File Plan

Other Utility/Contractor/Vendor Worker Access Request

BPA F 1400.22a

other utility, contractor, vendor, worker, access, request

BPA User

2015-11-23

BPA