Free SD Form 572, Cryptographic Access Certification and Termination, June 2000 - Federal


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Date: March 26, 2008
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State: Federal
Category: Government
Author: WHS/ESD/IMD
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CRYPTOGRAPHIC ACCESS CERTIFICATION AND TERMINATION
PRIVACY ACT STATEMENT AUTHORITY: EO 9397, EO 12333, and EO 12356. PRINCIPAL PURPOSE(S): To identify the individual when necessary to certify access to classified cryptographic information. ROUTINE USE(S): None. DISCLOSURE: Voluntary; however, failure to provide complete information may delay certification and, in some cases, prevent original access to classified cryptographic information. INSTRUCTIONS Section I of this certification must be executed before an individual may be granted access to classified cryptographic information. Section II will be executed when the individual no longer requires such access. Until cryptographic access is terminated and Section II is completed, the cryptographic access granting official shall maintain the certificate in a legal file system, which will permit expeditious retrieval. Further retention of the certificate will be as specified by the DoD Component record schedules. SECTION I - AUTHORIZATION FOR ACCESS TO CLASSIFIED CRYPTOGRAPHIC INFORMATION a. I understand that I am being granted access to classified cryptographic information. I understand that my being granted access to this information involves me in a position of special trust and confidence concerning matters of national security. I hereby acknowledge that I have been briefed concerning my obligations with respect to such access. b. I understand that safeguarding classified cryptographic information is of the utmost importance and that the loss or compromise of such information could cause serious or exceptionally grave damage to the national security of the United States. I understand that I am obligated to protect classified cryptographic information and I have been instructed in the special nature of this information and the reasons for the protection of such information. I agree to comply with any special instructions, issued by my department or agency, regarding unofficial foreign travel or contacts with foreign nationals. c. I acknowledge that I may be subject to a non-lifestyle, counterintelligence scope polygraph examination to be administered in accordance with DoD Directive 5210.48 and applicable law. d. I understand fully the information presented during the briefing I have received. I have read this certificate and my questions, if any, have been satisfactorily answered. I acknowledge that the briefing officer has made available to me the provisions of Title 18, United States Code, Sections 641, 793, 794, 798, and 952. I understand that, if I willfully disclose to any unauthorized person any of the U.S. classified cryptographic information to which I might have access, I may be subject to prosecution under the Uniform Code of Military Justice (UCMJ) and/or the criminal laws of the United States, as appropriate. I understand and accept that unless I am released in writing by an authorized , the terms of representative of (insert appropriate security office) this certificate and my obligation to protect all classified cryptographic information to which I may have access, apply during the time of my access and at all times thereafter. ACCESS GRANTED THIS 1. EMPLOYEE
a. SIGNATURE b. NAME (Last, First, Middle Initial) c. GRADE/RANK/RATING d. SSN

DAY OF

,

.

2. ADMINISTERING OFFICIAL
a. SIGNATURE b. NAME (Last, First, Middle Initial) c. GRADE d. OFFICIAL POSITION

SECTION II - TERMINATION OF ACCESS TO CLASSIFIED CRYPTOGRAPHIC INFORMATION I am aware that my authorization for access to classified cryptographic information is being withdrawn. I fully appreciate and understand that the preservation of the security of this information is of vital importance to the welfare and defense of the United States. I certify that I will never divulge any classified cryptographic information I acquired, nor discuss with any person any of the classified cryptographic information to which I have had access, unless and until freed from this obligation by unmistakable notice from proper authority. I have read this agreement carefully and my questions, if any, have been answered to my satisfaction. I acknowledge that the briefing officer has made available to me Title 18, United States Code, Sections 641, 793, 794, 798, and 952; and Title 50, United States Code, Section 783(b). ACCESS WITHDRAWN THIS 3. EMPLOYEE
a. SIGNATURE b. NAME (Last, First, Middle Initial) c. GRADE/RANK/RATING d. SSN

DAY OF

,

.

4. ADMINISTERING OFFICIAL
a. SIGNATURE b. NAME (Last, First, Middle Initial) c. GRADE d. OFFICIAL POSITION

SD FORM 572, JUN 2000

PREVIOUS EDITION IS OBSOLETE.

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