REQUEST FOR CLASSIFICATION/DECLASSIFICATION AUTHORITY

1.  NAME OF INDIVIDUAL FOR WHOM AUTHORITY IS REQUESTED:

    _____________________________________________________________________
    (First)            (Middle Initial)          (Last)

2.  TITLE AND ORGANIZATION OF INDIVIDUAL FOR WHOM AUTHORITY IS REQUESTED:

    _____________________________________________________________________

3.  MAILING ADDRESS: ____________________________________________________

   (incl. Org. Code) ____________________________________________________

4.  TELEPHONE NUMBER: ___________________________________________________

5.  LEVEL OF CLEARANCE: _________________________________________________

6.  LEVEL AND TYPE OF AUTHORITY REQUESTED:  (Choose ONE)

    ____ Top Secret Original                ____ Top Secret Derivative

    ____ Secret Original                    ____ Secret Derivative

    ____ Derivative Declassification*

7.  DESCRIPTION OF SUBJECT AREA AND JURISDICTION FOR WHICH AUTHORITY IS
    NEEDED:
    ____________________________________________________________________
    ____________________________________________________________________

8.  ANTICIPATED FREQUENCY OF USE OF AUTHORS: ___________________________

9.  QUALIFICATIONS OF THE INDIVIDUAL FOR WHOM AUTHORS IS BEING REQUESTED
    (ADDITIONAL SUPPORTING INFORMATION MAY BE ATTACHED):
    ____________________________________________________________________
    ____________________________________________________________________

______________________________________              ____________________
Signature of Requesting Official -                          Date
MUST BE OFFICE DIRECTOR OR ABOVE

______________________________________              ____________________
Name - Typed                                                Title

*Must attach specific justification.