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Header and Part I: Completed by user
All blocks must be complete.
LOCATION (Physical Location of System) MUST be HCS Kansa Kansas City no matter where you are located.
Block 1: Your name.
Block 2: Your government agency.
Block 3: Your units name.
Block 4: A number you can be reached at.
block 5: The email address issued to you by a government agency.
Block 6: Your Job Title and Rank
Block 7: is your units mailing address.
Blocks 8 and 9 are specific to you and must be checked
The date in block 10 must match the date on the cyber awareness certificate you provide.
This is the current list of accepted certificates.
Option 1 - Cyber Awareness & PII Combined Certification
CYBERM0000 USMC Cyber Awareness Training (Marine Net) (active and reserve military only)
CYBERC Civilian Cyber Awareness Training (Marine Net) (contract and civilian employees)
CYBERINTEL Intelligence Community Cyber Awareness Training Curriculum
ANNUALTRFYAnnual Training Curriculum Fiscal Year (MarineNet)
Option 2 - Cyber Awareness + PII individual courses
DODCAC1000 DOD Cyber Awareness Challenge + DONPII010A Department of the Navy Annual Privacy Training (Marine Net)
DOD-IAA-V17.0 Cyber Awareness Challenge V5 + DON-PRIV-2.0 Department of the Navy Annual Privacy Training (TWMS)
Cyber Awareness Challenge + Identifying and Safeguarding Personally Identifiable Information (PII) (DISA)
INTELCAC Cyber Awareness Challenge (Intel Community) + DONPII010A Department of the Navy Annual Privacy Training (Marine Net)
Your digital signature is required in block 11. Ensure the date in block 12 is the same date you digitally sign block 11.
Part II: Completed by supervisor
Block 13- Justification must match the system listed in the system name block.
A concise statement for why access is required along with the following information:
Site: Your location
Application role requested
Environment is NIPR Production
Any additional detail to specify access requirements
Example for STRATIS SAAR
Site: BIC
Role: ADM
Permission Group: Interface User
Risk: Annually Validation
Example for CLC2S
Site: (I MEF, II MEF, III MEF, MFR, etc)
Application role requested: (Clerk, Principal Staff, Rations Coordinator, Corpsman, or Unit Supervisor)
Environment: NIPR Production
Risk: MARADMIN 229/22
Example for TCPT
Site: (I MEF, II MEF, III MEF, MFR, etc)
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