MARCH 2020

NATIONAL DEFENSE UNIVERSITY FORM 2875

SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)
PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act. PURPOSE: To record names,
signatures, and other identifiers for the purpose of validating the trustworthiness of individuals requesting access to Department of Defense
(DoD) systems and information. NOTE: Records may be maintained in both electronic and/or paper form. DISCLOSURE: Disclosure of this
information is voluntary; however, failure to provide the requested information may impede, delay or prevent further processing of this
request.

SECTION I - REQUESTOR INFORMATION (To be completed by Requestor) Initial Request Modification Deactivation
1. NAME (Last, First, Middle Initial) 2. ORGANIZATION
Galeas Galvez Alexis Antonio AAGG Inter-American Defense College (IADC)
3. OFFICE SYMBOL/DEPARTMENT 4. PHONE (DSN or Commercial)
IADC 703944646480
5. JOB TITLE AND GRADE/RANK 6. EDIPI Number (back of CAC) or International Travel Order (ITO)
LTC 1624894746
7. OFFICIAL E-MAIL ADDRESS 8. CAC EXPIRATION DATE (MM/DD/YYYY)
alexis.galeas@iadc.edu N/A
9. OFFICIAL MAILING ADDRESS 10. CITIZENSHIP 11. DESIGNATION OF PERSON
National Defense University
300 5th Avenue, Bldg 64
US FN MILITARY CIVILIAN
Fort McNair, Washington DC, 20319 OTHER CONTRACTOR
12. SYSTEM NAME(S) (Platform or Applications) 13. ACCOUNT TYPE VOL/
Blackboard STAFF FACULTY STUDENT INTERN
14. JUSTIFICATION FOR ACCESS
To fulfill educational mission and MOU

15. IA TRAINING OR CYBER AWARENESS CHALLENGE CERTIFICATION REQUIREMENTS

I have completed Annual Cyber Awareness Training. DATE COMPLETED (YYYY-MM-DD) 2023-09-2023
16. USER SIGNATURE 17. DATE (YYYY-MM-DD)
2023-09-2023
SECTION II – ENDORSEMENT OF ACCESS BY USERS MILITARY OR GOVERNMENT SUPERVISOR
(If the user is a contractor – provide company name, contract number, and date of contract expiration in Block 19.)
18. VERIFICATION OF NEED TO KNOW 19. CONTRACTOR ACCESS INFORMATION (Required for contractors)
19a. CONTRACT NUMBER 19b. COMPANY NAME 19c. DATE (YYYY-MM-DD)
I certify that this user requires access as requested.

20. TYPE OF ACCESS REQUIRED

AUTHORIZED PRIVILEGED
21. SUPERVISOR’S NAME (Print Name) 22. SUPERVISOR’S SIGNATURE 23. DATE (YYYY-MM-DD)

24. SUPERVISOR’S ORGANIZATION/DEPT 25. SUPERVISOR’S E-MAIL ADDRESS 26. PHONE NUMBER

SECTION III – SECURITY MANAGER CLEARANCE VALIDATION

27. TYPE OF INVESTIGATION 28. DATE OF INVESTIGATION (YYYY-MM-DD)

29. CLEARANCE LEVEL 30. IT LEVEL DESIGNATION

LEVEL I LEVEL II LEVEL III
31. VERIFIED BY (Print Name) 32. PHONE NUMBER 33. SECURITY MANAGER’S SIGNATURE 34. DATE (YYYY-MM-DD)

SECTION IV – SYSTEM OWNER AND CYBERSECURITY APPROVAL

35. SYSTEM OWNER OR APPOINTEE SIGNATURE 36. PHONE NUMBER 37. DATE (YYYY-MM-DD)

38. CYBERSECURITY SIGNATURE 39. PHONE NUMBER 40. DATE (YYYY-MM-DD)

 INSTRUCTIONS

SECTION I – REQUESTOR INFORMATION

The following information should be provided by the user when establishing an NDU account.
(1) Name. The last name, first name and middle initial of the user.
(2) Organization. The user’s current organization (NATIONAL DEFENSE UNIVERSITY).
(3) Office Symbol/Department. The office symbol within the current organization (i.e. RMD, HRD, NWC, etc).
(4) Phone. The telephone number of the user.
(5) Job Title/Grade/Rank. The job title of the user (i.e. Network Engineer, Information Assurance Manager).
(6) EDIPI (back of CAC).
(7) Official Email Address. The user's official email address.
(8) CAC Expiration Date. Expiration date will determine the account expiration date.
(9) Official Mailing Address. The user’s official mailing address.
(10) Citizenship. (US, Foreign National or Other).
(11) Designation of Person. (Military, Contractor or Civilian).
(12) System Name(s). The systems for which this access request is being submitted (i.e. NEIS, O365, Blackboard, etc).
(13) Account Type. (Staff, Faculty, Student, Volunteer/Intern).
(14) Justification for Access. A brief statement is required to justify establishment of an account
(15) IA Training or Cyber Awareness Challenge Certification Requirements. User must indicate if he/she has completed the
annual training and the date should be within the current fiscal year.
(16) User Signature. User must digitally sign the Acropolis SAAR form with the understanding that they are responsible and
accountable for their password and access to the system(s).
(17) Date. The date that the user signs the form.

SECTION II – ENDORSEMENT OF ACCESS BY USERS MILITARY OR GOVERNMENT SUPERVISOR

The following information should be provided by the user military or government supervisor.
(18) Verification of Need to Know. This should be checked verifying that the user requires access as requested.
(19) Contractor Access Information. If the user is a contractor the user’s contract number, company name and expiration date
of the contract should be indicated in this block.
(20) Type of Access Required. Place an “X” in the appropriate box. (Authorized – Individual with normal access. Privileged
– Those with privilege to amend or change systems configuration, parameters, or settings.)
(21) Supervisor’s Name. The supervisor or representative prints his/her name to indicate that the information on the form has
been verified and that access is required.
(22) Supervisor’s Signature. The user’s supervisor should digitally sign in this block. For DISA users the supervisor that is
listed in CMIS is the one that should complete this section.
(23) Date. The date that the supervisor signs the form.
(24) Supervisor’s Organization/Department. The supervisor’s organization (i.e. RMD, HRD, NWC, etc.).
(25) Supervisor’s Email Address. The supervisor’s official email address.
(26) Phone Number. The telephone number of the supervisor.

SECTION III – SECURITY MANAGERS CLEARANCE VALIDATION

The following information should be completed by the user’s security manager.

(27) Type of Investigation. The user’s last type of background investigation (i.e. NACI, SSBI).
(28) Date of Investigation. Date of last investigation.
(29) Clearance Level. The user's current security clearance level.
(30) IT Level Designation. The user's IT designation (Level I, Level II, or Level III).
(31) Verified By. The security manager or representative prints his/her name to indicate that the user's clearance and
investigation information has been verified.
(32) Phone Number. The telephone number of the security manager.
(33) Security Manager's Signature. The user's security manager or his/her representative digitally signs in this block
indicating that the user's clearance and investigation information has been verified.
(34) Date. The date the form was signed by the security manager or his/her representative.

SECTION IV– SYSTEM OWNER AND CYBERSECURITY VALIDATION

This section (blocks 35 - 40 should be left blank and is for NDU ITD internal processing.