Registration form for Quality
Database (QDB) for U.S. Government Employees Please TYPE or PRINT CLEARLY then mail or fax this
form to:
Mail: FAX:
Instructions for completing this form
This is a
Department of Defense (DoD) computer system. DOD computer systems are
provided for the processing of official U.S. Government information
only. All data contained on DoD computer systems is owned by the
Department of Defense, may be monitored, intercepted, recorded, read,
copied, or captured in any manner and disclosed in any manner, by
authorized personnel. There is no right to privacy in this system.
System personnel may give to law enforcement officials any potential
evidence of crime found on DoD computer systems. Use of this system by
any user, authorized or unauthorized, constitutes consent to this
monitoring, interception, recording, reading, copying, or capturing and
disclosure.
Block 1. Agency Information
U.S.
Government Branch of Service or Agency:_______________________________
Major
Command:__________________________________________
Office
Symbol, Code, Mail Stop:_________________________________
Organization:________________________________________________
Street/PO
Box________________________________________________
City/State/Zip Code:___________________________________________
City/Country (if APO or FPO address:_____________________________
Commercial
Phone:_____________ DSN:_________________________
E-Mail
Address:_______________________________________________
FAX:_______________________________________________________
Block 2. QDB User Information. This form requests that you provide your
social security number. The U.S. Government is authorized to ask for
this information under Executive Orders 9397, 10450 and 10577 sections
3301 and 3302 of title 5, U.S. Code and parts 4, 731 and 736 of Title 5,
Code of Federal Regulations. Your social security number is needed to
keep records accurate, because other people may have the same name. The
primary use of the information on this form is for review by Government
Officials to determine and verify that you have the appropriate security
clearance to obtain access to the requested data. Disclosure is
voluntary. However, failure to provide the requested information may
result in denial of access.
As a user
of Quality Database (QDB), I acknowledge my responsibility to conform to
the following requirements and conditions as established by DLA:
I
understand the need to protect my password. I will NOT share my password
and/or account.
I understand that I am responsible for all actions taken under my
account. I will NOT attempt to ‘hack" the network or any connected
information system or network, or attempt to gain access to data for
which I am not specifically authorized.
I
acknowledge my responsibility to comply with all copyright laws both
federal and state (where applicable).
I
understand my use of DLA information systems is subject to monitoring to
ensure proper functioning, to protect against improper or unauthorized
use or access, and to verify the presence or performance of applicable
security features or procedures. By using the information system I
consent to such monitoring.
I
acknowledge my responsibility to conform to the requirements stated
above when using DLA information systems or networks. I also acknowledge
that failure to comply with these requirements and conditions may
constitute a security violation resulting in denial of access to DLA
information systems, networks or facilities and that such violations
will be reported to appropriate authorities for further action as deemed
appropriate.
I
understand the need to protect my password. I will NOT share my
password/and/or user ID. If I no longer need access to the Quality
Database (QDB), it is my responsibility to notify DLIS.
USER
SIGNATURE___________________________DATE:______________
Printed
Name:___________________________________________________
Social
Security Number:_____________________________________
DLA
Standard LOGON:______________________________________
Email
Address:_____________________________________________
Commercial
Phone:___________________DSN:__________________
Personal
Identification Information – (This may be your favorite color, sports
team, hobby or phrase.)
______________________________________________________
Block 3.
Supervisory Approval
This block must be completed by your supervisor.
Signature of Approving Official:___________________________
Printed Name:______________________________________________
Title:_____________________________________________________
Commercial
Phone:_____________________DSN:_________________
Block 4. Security Verification
This block must be completed by the Command Security Office.
Requests received without annotation and signature will be returned
without further action.
Security
Officer. Access to this system requires the user to have a National
Agency Check (NACI) or equivalent type of Investigation. If this level
of investigation has not been completed for this person, contact the
Defense Security Service at http://www.dss.mil for assistance.
Verification of Security for requester named in Block 3:
Employee
Name:_____________________________________________
Type of
Investigation: _____________ Completed on:_________________
By
(Agency):_________________________________________________
ADP
Level:__________________________________________________
Signature
of Security Representative: :______________________________
Printed
Name of Security Representative:_____________________________
Title:__________________________________ Date:_________________
Commercial
Phone:_______________________ DSN:________________
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