Please TYPE or PRINT CLEARLY then mail or fax this form to:

Mail:                                                                 Fax:
DLIS-TA (ERLS Access)                         DSN: 661-5925
Defense Logistics Services Center                       Commercial: 269-961-5925
74 Washington Ave N Ste 7
Battle Creek MI 49017-3084

This is a Department of Defense (DoD) computer system. DOD computer systems are provided for the processing of official U.S. Government information only. All data contained on DoD computer systems is owned by the Department of Defense, may be monitored, intercepted, recorded, read, copied, or captured in any manner and disclosed in any manner, by authorized personnel. There is no right to privacy in this system. System personnel may give to law enforcement officials any potential evidence of crime found on DoD computer systems. Use of this system by any user, authorized or unauthorized, constitutes consent to this monitoring, interception, recording, reading, copying, or capturing and disclosure.

Block 1. Sponsor Information � This block must be completed and signed by the U.S. Government Contracting Officer Representative.

U.S. Government Branch of Service or Agency:_______________________________
(Such as Army, Navy, Air Force, DLA, etc.)

Major Command:__________________________________________
(Such as Army Materiel Command, Defense Reutilization and Marketing Service, etc)

Activity Name:_____________________________________________
(Such as DRMO Lewis, DSCR, DDNV, etc.)

Installation Name:___________________________________________
(For example, Fort Lewis, Wright-Patterson AFB, DSCP, etc.)

Government Contract Officer Representative (COR).  By signing this block, you agree that the contractor named in Block 2 needs access to ERLS in order to perform their contractual obligations at your agency.

COR Signature:___________________________________________________

COR Name (print):________________________________________________

Office Symbol/Code/Mail Stop:______________________________________

Organization:___________________________________________________

Street/PO Box:__________________________________________________

City/State/ZIP Code:_____________________________________________

City/Country (If APO or FPO address):_______________________________

Commercial Phone:_____________________DSN:____________________

Email Address:_____________________________Fax:_________________

 Block 2. Contractor Information

POC Name:__________________________________________________

Company Name:______________________________________________

Street Address/PO Box:_________________________________________

City/State/ZIP Code:____________________________________________

City/Country:__________________________________________________

Commercial Phone:______________________DSN:__________________

Fax:_______________________Email:____________________________

Contract Number:______________________________________________

Contract End Date___________________________________________

Block 3. ERLS User Information

This form requests that you provide your social security number. The U.S. Government is authorized to ask for this information under Executive Orders 9397, 10450 and 0577 sections 3301 and 3302 of title 5, U.S. Code and parts 4, 731 and 736 of Title 5, Code of Federal Regulations. Your social security number is needed to keep records accurate, because other people may have the same name. The primary use of the information on this form is for review by Government Officials to determine and verify that you have the appropriate security clearance to obtain access to the requested data. Disclosure is voluntary. However, failure to provide the requested information may result in denial of access.

As a user of ERLS, I acknowledge my responsibility to conform to the following requirements and conditions as established by Defense Logistics Agency:

I understand the need to protect my password. I will NOT share my password and/or account.

I understand that I am responsible for all actions taken under my account. I will NOT attempt to �hack" the network or any connected information system or network, or attempt to gain access to data for which I am not specifically authorized.

I acknowledge my responsibility to comply with all copyright laws both federal and state (where applicable).

I understand my use of Defense Logistics Agency Information systems is subject to monitoring to ensure proper functioning, to protect against improper or unauthorized use or access, and to verify the presence or performance of applicable security features or procedures. By using the information system I consent to such monitoring.

I acknowledge my responsibility to conform to the requirements stated above when using Defense Logistics Agency information systems or networks. I also acknowledge that failure to comply with these requirements and conditions may constitute a security violation resulting in denial of access to Defense Logistics Agency information systems, networks or facilities and that such violations will be reported to appropriate authorities for further action as deemed appropriate.

I understand the need to protect my user ID and Password. I will NOT share my user ID or Password. I will input my password manually and not use scripts or function keys. If I no longer need access to ERLS, it is my responsibility to notify DLIS.

USER SIGNATURE______________________________________________

Printed Name:___________________________________________________

Social Security Number (last SIX only)____________________________________

  DLA Standard LOGON or User ID:__________________________________

Email:__________________________________________________________

Commercial Phone:________________________DSN:__________________

Personal Identification Information � (This may be your favorite color, sports team, hobby or phrase.) _________________________________________________________________

Levels of Access:

____ Activity information where employee is located.

____ Activity and Installation information where employee is located (they must have installation reporting requirements for this access)

____ Installation information where employee is located plus other installations including off site or generator sites.

____ Region information (read only)

Select one Type of Access: (refer to instruction sheet for category explanation)

          _____ Activity Group
          _____ Installation Group
          _____ DRMO Level 1 user
          _____ DRMO Level 2 user
          _____ Chemical Manager
          _____ ICP Group
          _____ HQ DLA

Block 4. Security Verification

If you are a DoD sponsored contractor you must have this block completed by your Contract Officer Representative/Security office.  If received without annotation and signature, your form will be returned without further action.

Personnel Security Officer.  Access to this system requires the user to have a National Agency Check  (NAC) or equivalent type of Investigation.  If this level of investigation has not been completed for this person, contact the OPM Investigations at http://www.opm.gov/extra/investigate/. I do certify that all information given in this Registration is true and correct to the best of my knowledge and belief, and that I have not knowingly omitted any information which is inconsistent with this registration.  I acknowledge that the submission of false or misleading information and/or the concealment of any material facts may constitute a violation of the provisions of 18 USC 1001. To expedite your request, please fax a copy of your security clearance with your paperwork.

Verification of Security for requester named in Block 3:

Employee Name:_____________________________________________

Type of Investigation: _____________ Completed on:_________________

ADP Level  ______________________

By (Agency):_________________________________________________

Signature of Security Representative: :______________________________

Printed Name of Security Representative:__________________________

Title___________________________________   Date________________

Commercial Phone ________________________ DSN _________________