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SAAR

 SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)

AUTHORITY: Executive order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act.

PRINCIPAL PURPOSE: To record names, signatures, and other identifiers for the purpose of validating the trustworthiness of individuals requesting access to Department of Defense (DoD) systems and information. NOTE: Records may be maintained in both electronic and/or paper form.

ROUTINE USERS: None.

DISCLOSURE: Disclosure of the information is voluntary; however, failure to provide the requested information may impede, delay or prevent further processing of this request.

TYPE OF REQUEST                                 

INITIAL   MODIFICATION   DEACTIVATE   USER ID       

     DATE
SYSTEM NAME (Platform or Applications)       
   
  LOCATION (Physical Location of System
   
PART I (To be completed by Requestor)
1. NAME(Last, First, Middle Initial)     
2. ORGANIZATION
                                                                                 
3. OFFICE SYMBOL/DEPARTMENT
4. PHONE(DSN OR Commercial)
5. OFFICIAL E-MAIL ADDRESS
6. JOB TITLE AND GRADE/RANK
7. OFFICIAL MAILING ADDRESS
 
8. CITIZENSHIP
 US   FN  
 OTHER

 

9.DESIGNATION OF PERSON
 MILITARY  CIVILIAN  

 CONTRACTOR

10. IA TRAINING AND AWARENESS CERTIFICATION REQUIREMENTS (Complete as Required for the user or functional level access.)

 I have completed Annual Information Awareness Training                                                                                                                DATE 
11. USER SIGNATURE                                                                                                                                                                                       12. DATE  
PART II - ENDORSEMENT OF ACCESS BY INFORMATION OWNER, USER SUPERVISOR OR GOVERNMENT OR GOVERNMENT SPONSOR( if individual is a contractor - provide company name, contract number, and date of contract expiration in Block 16.)

13. JUSTIFICATION FOR ACCESS

14. TYPE OF ACCESS REQUIRED:
 AUTHORIZED               PRIVILEGED  

15. USER REQUIRES ACCESS TO:  UNCLASSIFIED   CLASSIFIED  (specify category)
 OTHER 

16. VERIFICATION OF NEED TO KNOW 

I certify that this user requires access as requested.       
16a. ACCESS EXPIRATION DATE (Contractors must specify company name,
contract number, expiration date. Use Block 27 if needed
.)   
17. SUPERVISOR'S NAME (Print Name)
18. SUPERVISOR'S SIGNATURE
19. DATE
20. SUPERVISOR'S ORGANIZATION/DEPARTMENT
20a. SUPERVISOR'S E-MAIL ADDRESS
20b. PHONE NUMBER 
21. SIGNATURE OF INFORMATION OWNER/OPR
21a. PHONE NUMBER
21b.  DATE
22. SIGNATURE OF IAO OR APPOINTEE
23. ORGANIZATION/DEPARTMENT
24. PHONE NUMBER 
25. DATE

DD FORM 2875, AUG 2009                                                                    PREVIOUS EDITION IS OBSOLETE
 

26. NAME (Last, First, Middle Initial)
 
27. OPTIONAL INFORMATION (Additional information)

 

PART III - SECURITY MANAGER VALIDATES THE BACKGROUND INVESTIGATION OR CLEARANCE INFORMATION
28. TYPE OF INVESTIGATION
                                            
28a. DATE OF INVESTIGATION 
28b. CLEARANCE LEVEL 
                                                       NATO DATE
28c. IT LEVEL DESIGNATION
 LEVEL I   LEVEL II    LEVEL III
29. VERIFIED BY (Print Name)
30. SECURITY MANAGER TELEPHONE NUMBER 
31. SECURITY MANAGER SIGNATURE
32. DATE
PART IV - COMPLETION BY AUTHORIZED STAFF PREPARING ACCOUNT INFORMATION
TITLE:  SYSTEM            ACCOUNT CODE 
             DOMAIN                                          
             SERVER                                          
             APPLICATION                                 
             DIRECTORIES                                
             FILES                                               
             DATASETS                                      
DATE PROCESS
PROCESSED BY (Print name and sign)
DATE 
DATE REVALIDATED
REVALIDATED BY (Print name and sign)
DATE 

DD FORM 2875 (BACK), AUG 2009