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T No.: Nationality: Position: Company: Name: Date of Birth: Place of Birth: Security Clearance: ID/Passport No.: Nationality: Position: Company: 10. The Security Officer of the Requesting Organization or Industrial Facility Name: Telephone: Signature: For Government Use Only 11. Stamp Name: Address: Telephone: (Optional) Signature: 12. Requesting National Security Authority Stamp Name: Address: Telephone: Signature: 13. Remarks (Optional) Government Organization or Ind.

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