Security Clearance Revocation Form
Use this form to request, review, and document the revocation of a security clearance, including the reason, effective date, access items to remove or return, and final approval details.
Subject and Request Details
Subject full name
*
First Name
Last Name
Job title or role
*
Department
*
Company/site location
*
Subject email address
*
example@example.com
Subject phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Request submitted by
*
First Name
Last Name
Security clearance or access level being revoked
*
Revocation Information
Reason for Revocation
*
Effective Revocation Date
*
-
Month
-
Day
Year
Date
Revocation Type
*
Immediate
Scheduled
Temporary Suspension
Full Revocation
Other
Case or Reference Number
Primary Reason
*
Separation
Policy Violation
Role Change
Expired Need-to-Know
Other Documented Reason
Access, Assets, and Transition Items
Access and items to disable or recover
*
Badge access
Facility access
System accounts
Network access
Keys
Devices
Documents
Other company property
Access removal actions required
*
Disable access
Retrieve item
Revoke permissions
Update records
Notify provider
Other
Transition instructions and handoff details
*
Notes on pending tasks or required sequencing
Review, Approval, and Acknowledgment
Manager or Department Head Name
*
First Name
Middle Name
Last Name
Security Office or HR Reviewer Name
*
First Name
Middle Name
Last Name
Review Status
*
Approved
Rejected
Needs Revision
Pending
Approval Date
*
-
Month
-
Day
Year
Date
Comments
Authorized Approver Signature
*
Submit Revocation Request
Submit Revocation Request
Should be Empty: