PERSONNEL ASSURANCE PROGRAM CERTIFICATION/RECERTIFICATION
                         ORGANIZATION (EXAMPLE)


Requested for: _____________________________      ___________________
               Applicant's Full Name, L,F,MI      Department
               _____________________________
               Applicant's Job Title
               _____________________________           ______________
               Applicant's Organization Concurrence    Date

Observing      My observation of the applicant in a working environment
Supervisor     during the period ________________ to ________________ has
               revealed cause for concern for work with nuclear explosives.
               I have briefed the applicant on the DOE PAP and the need for
               reliable performance.  Applicant demonstrates a positive
               attitude toward the PAP.
               _____________________________           ______________
               Supervisor                              Date

Applicant      I have interviewed and briefed on the purpose and
Acknowledgment significant of the PAP and understand its intent and
               significance.
               _____________________________           ______________
               PAP Applicant                           Date

Medical        The applicant has been given a medical evaluation in
Review         accordance with the requirements in DOE 5610.11 and is
               acceptable for the PAP.
               _____________________________           ______________
               Medical Director                        Date

Personnel      The personnel file of the applicant has been reviewed and no
Review         information has been identified disqualifying the applicant
               from the PAP.
               _____________________________           ______________
               Personnel Reviewer                      Date

Training       The applicant has successfully completed the required
Review         training to be qualified from PAP and to perform nuclear
               explosive duties.
               _____________________________           ______________
               Training Coordinator                    Date

Organization   I have reviewed the above evaluations and forward the request
PAP            for certification.
Coordinator
Review         _____________________________           ______________
               Organization PAP Coordinator            Date

Security       Based on input from the cognizant DOE Security Office, a
Review         review of the security files has been conducted and no
               information has been identified disqualifying the applicant
               from PAP.  The applicant has a valid Q clearance.
               _____________________________           ______________
               Security Reviewer                       Date

DOE PAP        I have reviewed the above evaluations and all certifications
Coordinator    requirements have been met.
Review
               _____________________________           ______________
               DOE PAP Coordinator/Other               Date
               Qualified Reviewer

DOE            I have reviewed the above evaluations of the applicant and
Certification  certify the applicant's acceptability for nuclear explosive
               assignments.

               _____________________________           ______________
               DOE Certifying Official                 Date