NSLCPTSMH UAR

The following information is required for access to systems maintained at NAVSEALOGCENDET Portsmouth, Portsmouth, NH.
**Air Force Users fax forms to 937-656-2892**
**All others fax forms to 603-431-9464 **

Forms may also be mailed to:

FOR NAVSEALOGCENDET Portsmouth USE ONLY

____________________________

Naval Sea Logistics Center Detachment Portsmouth
80 Daniel Street, Suite 400, Portsmouth NH 03801 - 3884
Attention: NSLC 0514

DoD Interservice PQDR Application User Access Request Form
Section A
User Information (To be completed by the user requesting access)

Enter the type of User Access Request

NEW UPDATE DELETE RENEW ___________________________Date:

Personal Information
Government Contractor *(Contractor's see Note Below)

Last Name: First: MI:

Office Code : DODAAC:

DoD Service:
NAVY MARINES AIR FORCE ARMY DLA DCMA OTHER

Activity Head Title: (i.e., Commanding Officer, Commander, or other title)

Activity Name:

Office Address:

City: State: Zip Code:

Comm Phone: Ext: DSN: Fax:

E-Mail Address:

Section B
User Agreement (To be Agreed to and signed by the user requesting access)

As a user of NAVSEALOGCENDET PTSMH maintained systems, I agree to comply with the
terms/ restrictions as listed below:
1. When given a password, I will refrain from disclosing it.

2. I will not access the system under a false name or password.

3. I will not circumvent the security features designed into the system.

4. I will not attempt to access files for which I do not have access privileges.

5. I will treat all information examined or extracted as "business sensitive" or "company
confidential " (Level II) data pertaining to the companies whose data is in the system.

6. I will not enter, retrieve, or process classified information.

7. I will not transmit or communicate Level II data obtained from the system to any person, contractor
employee or government employee, who does not have a specific need for the information.

8. I will properly mark, safeguard, and destroy all printout and magnetic media according to regulations.

9. I will use the system for Official Government Business only.

10. I will notify NAVSEALOGCENDET PTSMH when I no longer need my account and advise
regarding disposition of functional accounts.

11. I will notify NAVSEALOGCENDET PTSMH in case of any security incident.

12. I consent to the monitoring of my data and processes by NAVSEALOGCENDET PTSMH personnel.

13. After termination, I agree not to retain any Level II or security data.

14. I will not program function keys or use other capabilities to provide an automatic logon from
my device.

I have read and understood the above agreement policy and guidelines. I understand that if I or my User ID
is suspect of misuse or abuse, that an investigation and/or disciplinary action may be taken.

________________________
Print User Name

__________________________
Signature

________________
Date

Non-Government Employee - Sponsor Information

Primary Government POC/
Sponsor Name: Sponsor Activity:

Comm Phone Number: Extension: DSN:

Contract Number: Expiration Date:

Supervisor/Sponsor Approval (Required for ALL access requests)

As the Supervisor/Sponsor of this user, I certify that they have the appropriate level of security clearance,
the hardware they use to access the system(s) is accredited, and that I will enforce the above terms/restrictions.

________________________
Print Supervisor/Sponsor Name

____________________________
Supervisor's Email Address

__________________________
Signature

________________
Date

NOTE: Contractor's must submit their request attached to company letterhead, or government letterhead if contracted to the government.