Security Clearance Refusal Form
Please complete this form to document the refusal of a security clearance request. All information will be handled confidentially and used solely for internal record-keeping.
Full Name
*
First Name
Last Name
Job Title or Role
*
Department or Organization
*
Contact Email
*
example@example.com
Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Clearance or Request Type
*
Please Select
Confidential Clearance
Secret Clearance
Top Secret Clearance
Site Access Request
Other
Refusal Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Refusal Reason (Summary)
*
Additional Notes (Optional)
Submit Refusal
Should be Empty: