ML20039C949

From kanterella
Jump to navigation Jump to search
Request for OMB Review & Supporting Statement Re NRC Form 1 (Parts I & Ii), Personnel Security Questionnaire. Estimated Respondent Burden Is 8,250-h Annually
ML20039C949
Person / Time
Issue date: 12/11/1981
From: Donoghue D, Scott R
NRC OFFICE OF ADMINISTRATION (ADM)
To:
Shared Package
ML20039C934 List:
References
NUDOCS 8112310135
Download: ML20039C949 (10)
v • d • e


Text

{{#Wiki_filter:r BETUEST FOR OM3 REVIEW (Und:r the Pap;rwork R: duction Act and ExSutiva Ord:t 12291) imp;rtant - Read instructions (SF-83 A) before completing this Office of Information and Regulato.ry Affairs form. Submit the required number of copies of SF-83.together Office of Management and Budget with th9 material for which review is requested to: Washington. D.C. 20503

1. D;pirtment/ Agency and Bureau / Office originating request
3. Name(s) and telephone number (s) of person (s) who can best I

answer questions regarding request U.S. Nuclear Reaulatory Commission 1 Dunleavv (1nli 497 anni 2.6-digit Agency / Bureau number (firstpart of 11-digit Treasury

4. 3-dignt f unctional code' (last part of 11-digit Treasury Account Account No.)

No.) _.3._ _.l 0_ P 0_ _ 0. _P _7 _.6._

5. Tstis of Informatnon Collect \\on or Rulemaking C. Is this a rutemaking submission under Section 3504th) of Pcrsonnel Security Questionnaire, NRC Form 1 P.L 96-511 ? (Check one)

Parts I & II 1p No(Section 3507 submission) 2O Yes.NPRM. Expected date of publication:

6. A. Is anyInformation collection (reporting or recordku 'ng) 3 O Yes. final rule. Expected date of pubhcation; l

involved? (Check one) Effective date:- 1$ Yes and proposal is attached for review D. At what phase of rulemaking is this submission made? 2 0 Yes but proposalis not attached - skip to question C 3 O No - skip to cuestion D. 1p Notapphcable B. Ars the respondents pnmarily educationalagencies or 2 0 Major rule. at NPRM stage institutions oris the purpose related to Federaleducation 3 O Major Finalrule for which no NPRM was published - programs ? 4 O Major Final rule, af ter publication of NPRM ~ O Yes ID No S O Nonmajor rule,at NPRM stage 6 O Nonmajor rule, at Final stage COMPLETE SHADED PORTION IFINFORMATION COLLECTION PROPOS AL IS ATTACHED

7. Current (or former) OMB Number
8. Requested 1,2. Agency r_epo,rt fo_rm number (s) _ _,

, _;, a,. Expiration Date - 3150-CM8 ~ ' ' ~ ~ NRC 1 (Part I and II) [ Expir;ti.on_Date.

13. Are respondents only Federal agencies?

l 12/31/81 12/31/84 O Yes 0INo - i

9. ls proposed information collection listed in
14. Type of request (Check one)

, th3information collection budget?

U Yes' ' O 'No 1 O prehminary plan.

_a 2 0 new (notpreviousty approved or expired more than 6 months i _10.Will this proposed information collection > Tago) ' c;use the a gency to exceed its information coll:ction budget allowance? (If yes, attach O Yes ^ p No 3.O' revision I ' ~ amsndment request from agency head.) 4 extension (adjustment to burden only)

11. Number of report forms submitted for approval 5 O extension (no change)

One (}) 6 0 reinstatement (expired within 6 months) 15.

16. Classification of Change in Burden (explain in supporting statement) e Appronmate size of unenese tirsamose' N/A No of Responser. No of Reporting Hours. Cost to the Public

-D 8'" "* D jg a.In inventoryI s i 1.500 c.Estimited number of -

b. As proposed '

8.250 r:soondents or m rectro teepers per year

c. Difference (b-a) 7 6.750 S

l 00 Id Reports ann' alty by each Explanation of difference (indicate as many as apply)' u

r
soondent tirem 251 a-,

- - - - ~. -~- aA,- I l i; Adjustments %, !T V' W ia,'_ L : O~E ~ F "r ,f, 5c n [5o's "'"

d. Correct $b-erro

}i G 6,750 is f 5.500 ^ I-

e. Correction-resstiin~ t5[1 i

iS I a f Estimatedeverage t ""*D"**"

f. Chiinge iri use -

V i i5 . perraponse 15 l Program chirig .N ', g Esttm;tec total hours f,j"judburoeni"

g. Increase

+ + +$ lur5m 15e s 1591 8,250

h. Decrease 8112310135 81121'4" Standard Form 83 (Rev. 3-81)

[ PDR ORG EUSOMB' For Use Beginning 4/1/81 i PDR

17. Absfract-Nnds gnd Us:s (50 wor (s ort:ss)..

Provides basic data for use in review of application for security clearance -or ~ access authorization.

20. Catalog of Federal Domestic Assistance Program Number (18. Rstit:d report f orm(s) (give OMB number (s). lRCN(s).i ye%,..

' intgn-Iagency rep _ ort form,numbit(slo.r_symbarts)) cM4 ? N/A 3150-0046 3150-0062

21. Small business or organization O Yes XX No 55.Typ3 of affected public (Check as manyas apply)
22. Type of activity of affected public-indicate 3-digit Standard Industrial Classification (SIC) code (s) (up to I o) - if over 1 CX individuals orhouseholds 10,' heck O Multiple or O All c

2 O state orlocalgovernments 3 O farms 4 0 businesses or otherinstitutions (except farms) _g _ _ 8_ 1

23. Brist description of affected public (e.g.."retailgrocery stores."" State education agencies,""householdsin 50 largest SMSA s")

Individuals requiring ' security clearances. 26.C_ollectiory' elf-administere'd'*l%L'E ll K 2:;Q

24. Purpose (Check as many as apply. lf more than one, indicate pt: dominant by an asterisk)

,11X mails 1 O epplication for benefits [ $ 0;ot,hef hel'ffahrNiriisferd" '-?d '[' & e =^ _2_ O program evaluation 30ltelephorie~iriterview 5O ,;;.[.i 3 O general purpose statistics j4 0[personalinterview . g n. -, '.3. j w. .2.. {recordk'eeping requirementV 'i ^,-'yearsM 4 (X r:gulatory or compliance [ RehI.rired retentjoriperiod'; ~ 5 O program planning or management 6 0 rasearch ' F5 0YtiseYdh5ib'E

25. Frequency of Use -
mpy.

. f4 7 - - 27. Collection agent (Check one) c'? -57, g [3 2 %-{d.g hh[. Recurring (check as manyas ap ly)l ] ~ [ p.. ~ '1 kegu'es,1,ing Depa'rtment/Agencygp - [ ' 1'O Nonrecurrint; 2 O,othe_r Fede,ral Department /Agencyg, p 2 p on occasion 6O semiannually . pr - 3 O private contractor ,j 3 O weekly 70 annually q , 4 O 'recordkeeping requirement _.,,,__ __, _, ; _,,,,,_,_ 3 O quarterly 9 0' o'ther-describe:. 7,L ~, ~. ~ 4 O monthly 8 0 ' biennially 5 O'other-describe: A d~ '$ho -

28. Authority for agency for information collection or 3oIDoLy'o[pIoriiisc cMf'ide~niiMityi.2/. Mc / i,,- T,'hd.

rul: making-indicate statute, regulation, judicial decree, ~ 7(If yes. eiplain basis for pledge -J.C*- ih+.Wd etc. 10 CFR 25 10 CFR 11 in sum rung statement). , J Yes _ O No p - 31.Will the proposed information collection create a new or Atomic Energy Act of 1954 become part of an existing Privacy Act system of records?

29. Rsspondent's obligation to repiy (Check as many as apply!.

(If yes. attach FederalRegister notice orproposed draft of 1 E voluntary -A notice.). . O_ _Ye_s ~ M.N o. ! - 2 O r: quired to obtain or retain benefit -

32. Cost to Federal Government of l

3 O mandatory-cite statute,not,CFR (attac,h copy okk.~ information collection or rulemaking S 9 yn statutory authority) 9 COMPLETE ITEMS 33 THRU 35 ONLY IF RULEMAKING SUBMISSION i 33. Compliance costs to the public l 34. Is there a regulatory impact

35. ls there a statutory or judicial analysis attached?

deadline affecting issuance? 0 Yeh O No O Yes. Enter date: O No CERTIFIC ATION BY AUTHORIZED OFFICI ALS SUBMITTING REQUEST-We certify that the information collection or rulemaking submitted for , r;vi;w is necessary for the proper performance of the agency's functions, that the proposal represents the minimum public burden and Federal cost consist 1nt with need, and is consistent with applicable OMB and agency it ' icy directives. Signature and title of: APPRo"ING POLICY oFFICI AL FOR C'iE NCY DATE SUBMITTING oFFICI AL DATE hMJ ' (X: Danie J. Donogh ph / jf f/ f t l l

+ j i SUPPORTING STATEMENT FOR NRC FORM 1 (PARTS I AND II) Personnel Security Questionnaire Justification Section 145 of the Atomic Energy Act (AEA) of 1954, as amended, requires before - an invididual can b2 granted access to Restricted Data (RD), an investigation and report on the individual's character, associations and loyalty and a determination that permitting such a person to have access to RD will not endanger the common defense and security. The basic security standard of E.0. 10450, " Security Requirements for Federal Employment," for employment, or retention of an individual in a sensitive - position, is that such employment or retention is " clearly consistent with the interests of the national security." Executive Order 10865, " Safeguarding Classified Information Within Industry," likewise permits the "... head of a department or his designee..." to grant access authorizations for industrial employees (NRC contractors and licensees) ...only upon finding that it is clearly consistent with the national interest to do so." 10 CFR Part 10, " Criteria and Procedures for Determining Eligibility for Access to Restricted Data or Nathnal Security Information," provides guidance in evaluating "...all the relevant information, favorable or unfavorable...", in order to determine "...whether the granting of access authorization would endanger the comon defense and security and would be clearly consistent with the national interest." Executive Order 12065, " National Security Information," Section 4-101~, is in agreement with the Atomic Energy Act of 1954 in stating tha. "no person may be given access to classified information unless that person has been determined to be trustworthy...". The implementing directive for Executive Order 12065 further specifies that the respondent's trustworthiness must be demonstrated to "... agency heads based upon appropriate investigations...". In order for the NRC to impleme'nt the responsibilities outlined in the aforementioned documents, it is essential, from a security standpoint, that the NRC receive all relevant information which can be used to determine the trustworthiness of the respondent. NRC Form 1, Parts I and II, (Personnel Security Questionnaire) is the principle form by which this relevant information is furnished to NRC. Additionally,10 CFR Part 25, " Access Authorization for Licensee Personnel," Section 25.17(c), identifies this form as a part of an NRC security packet to be completed by the respondents covered by this Part. The information supplied identifies the respondent and his/her relatives. It also provides information such as previous employers, citizenship, previous residences, education and organization membership. This information permits an initial

l 27 security assessment by the NRC Division of Security as to whether or not any information on the form has an impact on the respondent's eligibility for access authorization. For a "Q" acces~s authorization,the completed forms are sent to the appropriate Federal investigating agency where a full field investigation is condQcted. For an "L" access authorization f the completed forms are sent to the Office of Personnel Management where a National Agency Check or National Agency Check and Inquiry is conducted. The results of the completed investigations, checks and inquiries are returned to the NRC Division of Security whereupon an evaluation / determination is made, based on any developed information, as to whether it has any impact on the respondent's eligibility for access authorization. l The NRC Form 1 provides pertinent respondent information which enables the NRC Division of Security to fulfill its responsibilities to assess the respondent's trustworthiness and eligibility for an NRC access authorization. Being able to make this assessment benefits the NRC security paogram, the U. S. Government and the public at large by assuring that the respondent is one who,having access to National Security Information or Restricted Data, will not endanger the common defense and security. There is no source for the required information other than respondents. Description of the survey plan Not applicable to application requirements Tab'lation and publication plans u The information collected will not be published. Time schedule for data collection and publication Data is collected from submitted forms and submitted to appropriate agencies as collected. Consultations outside the agency There has been no consultation held since the last clearance. Estimation of compliance burden Previously, 6,750 burden hours associated with NRC 1 were calculated under 10 CFR 11, 3150-0062. This burden is now being deleted from 10 CFR 11 and cleared under NRC Form 1 to ensure all burden is properly accounted for. Part 25 Approximately 1,000 Form NRC-l's are processed annually. 2 e '~

-s 3 3-i The' burden for each respondent is estimated to be about 1.5 staff-hours. The burden is therefore 1,500 hours. Part 11 (transferred from 10 CFR 11, 3150-0062) Approximately 4,500 Form NRC-l's are anticipated annually. The burden for each respondent is estimated to be 1.5 hours. The burden is 6,750, The total burden is therefore 8,250 hours-annually. Estimate of cost to the Federal' Government The Federal cost is approximately $9,250 which includes review by GG-6 level personnel, file maintenance, mailing, and the cost of printing forms.

Enclosure:

NRC Form 1 4 6 e 4 ,)

12 4 l mR NRC Form I (PART I)(t48) U. S. NU. CLEAR REGULATORY COMMISSION 9p.eys ***""** '"'8 Eac1ption to Standtro Form 83 Washington, D.C. 20555 W Appr$ved by NARS (17?) NRCM 2ICI PERSONNEL SECURITY QUESTIONNAIRE /.2 ^ U INSTRUCTIONS - NRC FORM.I HAS TR O PARTS. ALL SECTJONS OF BOTH PARTS MUSTBE COMPLETED. UNLESS BOTH PARTS ARE COMPLETEL Y AND PROPERL Y EXECUTED. THE FORM WILL NOT BE A CCEPTED. Before any entries are made. familiarize yourself with allquestions. Do not sign withoutfirst reading the instructions and certification at the end of theform. TYPE OR PRINT ALL ANSWERS.. If more space is required, enter in item 17 on the back of this form or attach addstionalsheets andindicate theitem numbers to which the answers apply. Questions which do not apply should be marked **None". I. NAME (Last, Fsrst. Middle) g

4. DESCRIPTION,

..,-g. - 3 m... - r-. w wa =mu c.w r-c.w n.., q= .**'_.e e y.

2. ALL OTHER N AMES (include maiden name, names by former
5. SOCI AL SEC. NO. (See lastruct.ons)
6. BIRTH Mor t h nay year

. marriages, and dates that names were used) **

  • L-ql * - '

D AT E ~ {,'

.'? % &.

^ ..:&. a e..-

7. DI RTR PLACE (City, County, S. tate, and Country). -....

..' p;;

  • y..s.. ; ' a

.~..s. >.V >. : ~ :. s- -6~.- r 's s;. : '. ^ .: ~ * . >-i,..c. -) y :

  • s.

n.:s.; z. sa r.. " ~ - .t m :. v. ~. ? y-* .,. 3 - .,r.- ,.m 8.. Put an "X"in Appropriate Box: Single O u.rried O wido-rer) O ni.orced O

3. PRESENT RESIDENCE / Street and Number,.,

If divorced, enter narne of divorc.ed spouse (s) with date and place of divorce (s)... NATES City and State) ...r: -. .r". - ~ ~ *. g

9. A.L.L OTHER RESIDENCES FOR PAS.T I 5, YEARS DATES
10. CITIZENSHIP:

U.S. O ^'ien .;..'g,-.9 - . ;.1 r '.M L A. lf U.S. Citizen, indicate whether: .c (I) By BirthO ~ MB (3) By Naturalization O 9' ~' .. I ?.8 ' * ~. -y W (2) Derivative O ^ hen Registration No. Date Petition No. Certification No. Date ' Place Certification No.' s * '.i. pg ce s .m., -.i.. r-n . ~. B. If alien. indicate: (1) Alien Registration No. (2) Present Citizenship ~ ~ - ~ (3) Date of Entry (4) Port of Entry

11. MILtTARY SERVICE (Past or Present)

Seri.1 Nas Br.nh From O r b Te(YrI ~ M.., *. ;. u. n2. EMPLO YMENT tisst ALL employment dates sneludsngpresent employment and ALL dates and addresses when unemployed. lf any employments required a security clearance or access authorization, indicate this fact after the name of the company or organization which requested the dearance. Give name or names under which emploved if different from name now usedJ <c h,. .t, E=.,. 7.c s nrA m,d.r., , o TFPs of Warh Sep r's Naune Aa 0.w .... o .e a h rw 4 ,.. ~ s 6 ..a. ...t .g ~

7...

~ .,r.,. .- - s . e .~. m. y s-y.. ft. y;. ~4 F%.

q'sDt..L a.-

a.= n . m w: ~. '; : .' -d 2. v~b:,.5,,c. .p. 7 -.5y--- .s- .c.. ~ y n:. :p. n .:u a m ~. g ;)- NNE ,[ w M.~ s.T - I' '. zY-[. ' 3 -[W ..... E. ',-. ~M, ~ b /.. e

. w.y. w

.. ww, m. x s c.. .g m _- A** ,q

s. ;,-e a

-f ;. ,.y.;> 73,,,% f;e: r t 7 3. ;.fc'":*jrs, p. j ; - ' yh. g_,-- " f f c e;r,7,. . '~ ~% p.. u- + f... ..s. p-- ~ ~,.. --,,s.

.... ~~.. n. qq' w l.p; *.*

- +' 3.-?. 7.g.

  • ', y,.., 4,, 'O, E j ' *h y',,?[ Q g*M G.,.f. ' *-'

. -h,.. .w

v. ;

f 1 _ t_] *,* .,s,., . v

  • ,j..*-

.-s + .,,..n.< pars ; - . s,..' g 7 -4 - g A

  • (- v ; b, c. *.y.

~. - -=. .. i.. ,t. . r : :n. gr. ;..

  • .. =.

e. ..". *+. .a....e.n .y- . c A,,. -%,.C % P ar -e.4.;q.s. ,. s .w e .. n.,. > p.% g..- . s ,y. r.. e r s,. ,.,.*.t. -..%c s.- .r. i a.. 1.4 - c., < - +*

m. r.p.

.py. g p 4

  • Ts.

. U~ ~,,.. .e c.-

n S 3. FOREIGN COUNT.siES ViStiED(Exclustre ofAfilisory Service cnd U.S. Government Official n: vel) Co " tr* Porpsee Jo. y left US A

  • Date Ree rnee USA y

r .; -"N 4- _.y

14. EDUCATION (AllSchools Above Elementary)

\\ No e of sche.e A4de e From To D.ev.e '. ~.

  • T

~ .e- . a;R g.- s = n.- - e a.., ,,..a . ~ 5, ..- t o. t. . n. z. s-e. f r4 .'*c.,. F ,t ..., Q,.. :*; *:, ? s ..'*.1 .:s ' t -lm.. , 7 rf,;O'* * ' :-}

,-<j 4*.

= r.: 9 s - %8 Y,, i ;i.[ t ,,' ' }*l'l , l *. Q f.%f*; m.l ,.'(s - -n n..- ., :, m,.:. - -

.?

,,;l, -3 .- e - y r* ~. v.,'.

  • L G,.~.{ g.

.s C,: %.g'

  1. 2 s

n S S. REl.A TIVES treresse, esepperente feuer parense. spewe, dwereed opeesee or opeure, eksidren, esepensidren, broshere. enters, nuerbrennere, esepeasure, half brothere. helt eentere. fatherwiew. ead mether en law, lasang er deed. Nome of aposee shoold inelade maiden name eed a ny esher ne mes by preveeen marrsage. lf opeone a en elsen er if yee merry embeeement - to the esteeseen of this tweetsennaire, it analt be neesenery that data eeneersing year Epeone be fornaked een NRC Term 454) neiei.ee Nome 6eF.a Deio et s.run Addrene coenary et e. rih c.Pr eet, .e m e u. ,e .s, t. L. r , e . e.: ~ s f e. sS. REFERENCES (Name Three Persons. Not Relatives or Employers. Who Are Well Acquainted With You). N.m..eF.n s... end Home Addreae Yeare Keeen s b r ~ CER TIFICA TION l kne tre 2 eli of the ebeve enestsene and the snetreetsene and the Prisseer Act Statement prevededfor thse form. Icertify that the enfermehen forniahad en ensaver se three eeentsene w terrect e.ed complete to the been of my kneeledge end brisef. I mehr thse stesement to the Noeleer Regelaterv Commsensen snelenternly aesth the enderetendeng thes theinteramehen herren aus!! be eerd by federet innretageswa ege.nesee avhsle tenderting e enterety snventsgessen for she Neeleer Regulatory Commisesen for the perpeer of determans'ne my elsesbsisty for e neceresy alterener er secean eeshorneateen ender she enshorntr e/Seekene l45 end l61tiief the Asomse Energy Aes e(1954. ee emended. end Esteeswe 0rdere l0450 and l0063. lferther enderesend that the informatsens may else be need for any of the reenne eeen aseted in the Prnvery Act StatemenL Ireelae shet she daelesere of thin information is'anolensary. However.feilere by me se eEspoly o!!er eny pers of the reemented information mer' reeels in thse eoplseetion not besne pro weer2. y iforther enderstand that any felee etenement er omseneen of maternet feet may be enffsewns reeen for re:reuen of my appletenen er damneel efter employeeens end that any telee.' esaseme.t Am,n mey be penaked.e e teleny.ader Sect.en 100r. rear is. v.s Code. u - c. s - y... y' +; vg.ac,..., y.. ;.,. -l. ,.y,.*a ,+ . ; e.. -., w.. e %,. p .e 3, %.. ..~:~ 4 s .(Date and Place Where Signed) *.3. a:; ~~ ' (UsualSignature of Person Filling Out Questionnaire). (Sign OriginalOnlyl'. 4 U-s. / 4.X ;** 7 - " TO BE F1LLED OUT BY AGENCY OR F1RM EMPLOYING 4. # ' "ke*-.M./o- ' & @^ GREEF DESCRIPTION OV DUTIES (Description should not Reveal Classifiedinformation) NAME OF AGENCY OR FERM. ::< ?,- ' * ~ h.':y: .: u ~..,,

~ ;.

"t.~.- -,#~.,

  • a rt.% '.

<1[

h. t,..*n.e.*

.;ci.jje.s".' &,...a T a, s .. s ~ .. g,s.,r

  • =-..e.-

e< :. t ..y ,, A,,y ADD RES.S*~.f.*,. - ^ '

  • c.

, C:.m.

<o - ',. * ~

.~ * * * - .+ u.; ~ ~~'.*,C t s ,c., ~. h.n.t. ' 's ').a n.. .s a ... ~ ; &... ts' ~.t.-

54. (,

' ' 1cl h s e ?.r.~.M.'"l"* ;.6.

  • 4. j g.3 t o. 43 7,.e.,lf,'{^..., L {
  • g~

t .. *.~ 4 Y.*e[.,, 4 "

  • 4+

.'6, e .'k ..

  • v
y. j.T..?.

f WILL l'ERSON HAVE ACCESS TO:' ~ ~ ~ 9 g. 9 RESTRICTED DATA yes L.J ao

  • 1 OTHER NATION AL SECURITY INFORMATION yes O no (Sigteture and Dlle of OfficialRequesting clearance or Access Authoritatson)

UNCLASSIFIED SPECI AL NUCLEAR MATERIAL yes O no . r- _ _ = _

..4 .4 PLEASE-Befora Aaking a;.y Entries u This Side: (t) R; move and Reverse C;rbon Paper. (2) Reverse M. Order af CIpies (in. C py One Front Sida ('Originnt) is be C py One Riverse Sida Also.cte.) ,17. ADDITIONAL SPACE FOR FURNISHING INFORMATION IN ITEMS 1 TO 16. (hrdscate s' rem trumbers to Wrach answers apply.) . Aw. Itrm No. gi u .. s... ..r. .t n.g, v .g. r x.: .s. e.. . ~.. ~ . 1. <.T s ....c....,. .....v...w..~,.., <.. s m. .....7 .i. .s,. .c. g a 7,,

  • . ~.,:

_1~. ...J h...M.,. m......-, .1, i,.. .... /;.i %. : C6 Gs b s '~'. ' .~ - s q_ *w ~. g (,%,,.... - ,.,, ~.. . y-., ,,f, s d._ s + - ~.. - v% g. ,,-.2*,*.

  • g,.-

Y,, a. .~se. --..a. .,.n.w. _-a-A,

z. p. '....~a. 2. G.M. s. * '

. - ~. -.... -... - .a.... r. - - 1 t .s. - :f.Fp..ly: A...q T -1. l. :. a .

  • 2.m Q A.e.:- w

.sc.. j ^'

..,C.*

'.. :.. : p. *.~; ' ' W.:., P . a. , 4 w,,.... -..

  • e.

..---...v. ..3 -4.. , = _.,,..... s. L... 4 c. s.....-c ...p .r: r

4. P.'..

f .. w. x.. m s e s .s e. a. u. s ; s s .n... 1 n --.s p. y.3.. --C Ns - .,y..y + m,.....u. -u .p .,... +. ..., a s a. ....3 e. . v. M. 4.. 4 ^... C, r... + ..s .g...s. w - e,....t.. ., 4.e.

9... - %,

r a..y,w...._.. s..... . a .Q..-..~,.-...a ,'s. ....p s.. w .a ,-1 s.. ..p.. .e m. . s 3,.. .# y 5 , e.c. w.... m.,~,,... m. o-.. s .s --. ., to 1,- (. f.*,,.4

-... i.

..s. . i .s.. ,.w. .c.,. w ~ -..w.~- , g. . s v., ~..n.... o .a... e. . a s,.- .s a ~ ,s. ., ~. ,.,........m. ....._u... e._ f. .L T.- ;.. - ?..,r... 9.- -~, ;

~

4 ._a. . ~.- . vc., s... .4 ,.(. - s ..e ... r. c. .. r. p :;a. ?:. . r: r... i g 3 ..L~ a.. ~.. .m. .s g.a 3, ,.:- h - 7.,u ~.. . - v..,. -- .s m .m. - - J.. '....d :~., . a, -,.:: .~-.. m s .w p+- i. .. r.a ;.3 n. s.g.. u -

r., g:

~ .v.. " .?. 5..-- .s ... a +~ s. s.c. -... 1 .1 - ..r.. . ' t; '* . J,

- ' na.
  • - ' -'*. J. ~.'

n .y *;s

... 3.. ~...n,,,.

x,. ,s . ~..;, .a,.,.. s. w ~ . u,.. m, :.. s ~.u; .' 2. '". p..L.., 4. s 3,. ..q. g.'a.. *. - :.,.....,..r,.,- f,,.. .7n..,,. .s -....r t n_- J.w.

  • m'
  • 2..:

..- e.?.'

  • u - -'.g.e

- --- a r - ~ -.... .. ~ p: ~

, g;.., -

.g..2 t.,. .r., w,.

y 1.-

..~ .a es. :::::,:, _: s ~ .? ..>....,.q...:.-a r. ,.~.. -, .n.... i .s..... w.v - r: s.. ..,..., ~...v. s i. .e....s

4.....,

.y, ~. - o... u 2 .y.

-.?.

,.. o., M... ..3 w.n -. fv,.. .. e_. ..e..,. ~..:.... ~; p s rm .e M.- w,M m,o.::. m. 2-s... - ... : s, .a..... r -.., M.. rw- ., W :. r,... ,. c. m.. n.. ..,..w.... r+...... n:s ~..t.. .m. z.. - 3.m. m,. -.,.. ..r+. m w&:..t;. M- .... n m ..u +< .. ". w T: '...,. ., ~. -~ ? 2,r s6 ...?? ..;-... w:= f' . r R. ; i..~. w ' ;' e o. _ 9. ', ^

v.. m. -,..~.

.. s ......-.c-.. .w -;s.1 4.. .a ~ ..: w . -. ~.. - .4 ... ~. n. s .'.=a4%4- -.4.%.. .A'. ,4 r .: Tf ;;.', *.

    • ". ? t.. q.. ;%.._ -...

J. f.* ' ' _,.,._..,s- , t.e'. 3 -M,t'. g Y

  • _ 9 ; y L.,.,.-._ -. __,, f

,j 4,. ".*, .. ew.

v. 6

.. w ~. - .a. m,. *, - .> g % a...,- *,,

  • g

~r.. y*. .. @.,s...,... a... j.<*S.,, e.g ; .4-f e g se, e n. .e.. y 4 F

3. e...

-..,.,v.-y., y. - s .o.-.. -.e.s...,., s b I g N# I-3 G I .L' +.. ' ee .e. g e.. e y.

y Nac Poau wAat o W.m3MLEAWWEGULATORY COMM SGION ygedh= WASHINGTON, D. C. 2Dass Lunares 4.metL p,y EXCEPTION TS STANDa"9 FORM as ' APPROVEJ SY NAR$ tvaal P E R S O N N E L S E C U R I T Y Q U E S T I O N N A I R.E t. NAME(Last First,Mccie) 2. SOCLAL SEC. NO. !3. NAME OF AGENCY OR FIRM EMPLOYJNG tsee insuuctensi I ~ INSTRUCTIONS - COMPLETE THI9 FORM 'N PRIVATE. ALL SECTIONS MUST BE COMPLETED. FORM WILL NOT BE ACCEPTED UNLESS I COMPLETELY AND PROPERLY EXE.,UTED. Answers or statements on this form will be treated as conMentialin accordance with the Privacy Act of 1974 and the Nuclear Regulatory Commission's implementing regulations found in 10 CFR Part 9, subpart B. TYPE OR PRINT Al). ANSWERS. Write

  • * * "None" when applicable. Enter in item 10 any additionalinformation which may have a bearing on your security clearance. It more space is required, stuch add;tional sheets and indicate the item number to which the answers apply. -

4 A Ar yo; now, os within the last 10 years have you been a member of arry organization or group of persons inclu' ding but not limited to the Communist YES' ' NO i Party, U.SA. which, during the period of your membership or associaton you knew was advocating or teaching that the Govemment of the United - O St;tes, or any State or any political sutxfivison thereof should be overthrown or overtumeo by force, violence, or any unlawful means? -- - B.lf your answer to A is "Yes", ad you, dunng the period of such membership or association, have the specihc intent to further the aims of such organi.. YES - NO nton or group of persons to overthrow or overturn the Government of the United States or any State or any pohtical subdivision thereof by force. - O voence, or unlawful rneans? 5. If your answer to Queston 44., above is "Yes", hst below, continue under item No.10 or on a separate sheet to be attached to and made a part of this questionnt re, the, names of all such organizatons and dates of rnembership. Give Complete details of your activities therein and make any explanalson you desire regarding your rnember. sho or activities. - .o hAuE ADOAE SS FAOW To 1 OFFICE HELD ~' s v 9 6. ORGANIZATION MEM BERSHIP include att present rnembership and all past membership cunng tne last 10 years in all organizatons (eacept Labor uruons, rehgcus organ-izitons, and pohtical organizations) not covered by Questions 4. and 5. above. Ust in futt. If applicable, or state none. ~ >AuE ADDRESS TYPE FAOu To OFFICE HELD 9 7. Have you ever been arrested. charged. or held by Federal, State, or other law enforcerrr-t authorities for any violation of any Federal law, State law' YES NO county or municipal la w, regulatcn, or ordinance? Do not include artything that happened before your 1oth birthday. Do not include traffic viosations for which a hne of $50.00 of less was imposed. All other charges must be included even if they were dismissed. 8. It uswer to Question 7. is "Yes", complete A, B, C and D in each instance. A DATE B. CHARGE NgM$%E C O. ACTION TAKEN I 9. PREVIOUS SECURITY CLEARANCE OR ACCESS AUTHORZATION: YES NO O A To your know' edge have you ever been investigated by any branch of the Federal Govemment? YES NO B. To your knowledge have you ever been refused a securrty clearance or access authorizaten by any branch of the Federal Govemment? If ye fr answer to orther A or 8 is "Yes", please fumish details in item 10.- CERTIFIG JION. I have read all of the above questions and the instructons and the Prfvacy Act Statement provided for this form. I certify that the informaten fumished in answer to these ques. tons is correct and comp!ete to the best of my krwedge and belief.4 make this statement to the Nuclear Regulatory Commisson voluntarily with the understanding that the - informaton herein wdt be used by Federal investigatNe agencies while conducting a security invest $aton for the Nuclear Regulatnry Commisson for the purpose of. T det2rmining my eligibility for a security clearance or access authorization under tne authortty of Sections 145 and 161(i)of the Atomic Energy Act of 1954, as amended, and G Esecutive Orders 10450,10065, and 12065.1 further understand that the information may also be used for arr/ of the routine uses stated in the Privacy Act Statement.v I rialize that the esclosure of this information is voluntary. However, failure by rne to supply all or any part of the requested information may result in this applicatert not being A - proc:ssed. I further understand that any f alse statement or omisacn of materlat tact may be suffenent cause for rejection of my appncation or dismissal after employmert; e o further, that any false statement herein may be purushed as a felony under Section 1001 Title 18, UJS.CodeeP -J s.;P y.q

7.. 7 s '

a...; h, a c. } ,p

c. _,...
  • c, % ;:.

s. i '.' .,c : c. +, - .... L- ' *. :~; M3.....~L-.-. :..., .2.:.N:1.f.=::.L. '... = >.. .., u 4,.. p, - (DATE AND Pt/cE wHERE SIGNED) l (usual $4NATURL OF PERSON FtLLINGOUT OuESTsONNAiRQ, . ; - ColGN ORIGINALONLY) INSTRUCTIONS TO APPUCANT UPON COMPLETION OF ABOVE Now that the form is signed, place it in the pre 4ddressed envelope fumished, sign across the envelope flap - on the line provided, and aft 6x ine date of signature. Submit the sealed envenape with the other security forms included in this packet. b'

. m _ s s s n. s s .s e,. ~~ .ea 8 EASE - Sofore mak% a7 entries on tNs side: (1) Remove and reveres carbon papet. (2) Reverse the order of copies (l.a. copy one front side'(original) *E be copy one t rewt Q Qe eenio, etc.)

10. ADDITIONAL SPACE FOR FURNISHING INFORMATION IN ITEMS 1. T.O 9. (Indicate hem ramtiers to which answe.rs.applyJ

..~

u.. - _.

ITEM PC. 'u e 9 s f e... ',,,.r,.- s. .a.. e,.; + me. e e ./*

J 7.',.,

', *,,.t.1*". - ;,s. s +, i: "5- 's .w...*-

e. '=A, r, *

.# 't .t s ,,..v. :, tr*v w w- ..,a a. u,.:. -.. r. .r. i - s. ..E ,.,s. Ti ' #ff. e. '.. k.' f ( p. 3.. ' .u= 3h* * ' '. -. - ". 4 t * ,.*s* SJ i:* ' ":4 ** '

?J.-

. ;,.W.~ i - -~" - ' .s. :

  • a

.s. _, * ., s i.a;.eWY.. 't'W.

  • * - ~

,e kp'"".**.,,,, B-g. _ **,;. e. ' "...

  • 4'

+ .,C. - * * *. a. ,JJ4tV J'. < T. c "-O 'P-.** '*a.*-'

    • ~-A m

..F,

  • 4..*

.e s

  • .r
  • *... ', s.'

. s..*.. s. i < +, a.1 ' - t *

  • p ar. r 5.',. f e

. ;* 1

3.,, -

,, A.;.,4, p.,,- .U .e'**'N 6 g = +. .a.r..z.. a e o o e s. r.

  • y, 9g.

.e

=

s s g+ s C. ..r- . m.., .*c y.* N*' .'*; M.jp l*6

  • ic p.'. *<r

~ .., ;.- i _. -

  • '~ r.-- _
  • a.*

t~.. M s e t e -.s .s s 4 s-o. a. '.. ; 4

  • s 4.
r"

.i J.M, S. ~ 4*.'"

  • - (,...
  • 4 '

.Ce,- + s- -e t. i = ..,..,.,.4 + s .. =., s* J** i. s, =s r - 4 i*,- g

2..,

a n ^ ~ ~

  • 2 *; s: -.s ': =<.

~ . Vs.. k.. .J* a. . + -.'. - - g j. .s .n '..,.; m u s r-. s 4 ' 3.-..a. . +> w..

  • ..e..

=,o. =.. -, n.

  • * *
  • i','.., f"p[*
  • b,N -.

er I. ".#

  • 2. !

..:,,i',* .l h 4..

  • /. '.*d
  • b 4
  • 77 *.e;,.

f s ,f, . :P 'e'., ! N '..., [,((g ' af i, c1 .;* y,..[ 7 6m. i e, {. ,.g '33, ( e,$ i ge' +.. .Q. -../:** ~r*. '.. .s ..,: w.., v, .e. m , ~,, s ...y...- . a:.' c e: n.- .M.w gs. m. s* ..p... e..,~

..* g. A a

.t s. . _..e... -....... w

  • 2,,
  • .- *s...s.-

r- ., :. ~..,'.-,,

    • J # [, g..,,
  • j p',*

.. j a. co., ca.*:. ..O. ~a.. ',* f..*,.4.[. w). .. %...,sr*. : { a,. . ' f

  • .[

pe*. 8 to ,4 ..Kw " *, m. -...'.L. ,9 ..-- g a.

  • i,

.,r. e g p e

s 4

.s

  • f.g a

g r.. . J 6...e e.. e. .}}

Retrieved from "https://kanterella.com/w/index.php?title=ML20039C949&oldid=4562455"