Utility Maintenance Contractor Security Clearance
Contractor Information
Company Name
Address
Contact Person
Phone Number
Email
Project/Work Details
Project/Work Title
Location/Site
Work Start Date
Work End Date
Scope of Work
Personnel Requiring Clearance
Name
Position
ID/Birthdate
Clearance Level
Access Requirements
Areas to be Accessed
Equipment/Tools List
Notes/Additional Requirements
Authorized Contractor Representative
Signature: ________________________
Date: _____________________________
Utility Security Approval
Signature: ________________________
Date: _____________________________