<p> HSIN-CI Dams Portal (Access Request)</p><p>Upon completing the form, please email to the HSIN-CS Dams Portal administrator at [email protected]</p><p>Access Type: Portal Training Courses Date of Request (mm/dd/yyyy) Requestor Information Name Title Agency / Company Component (Department, Division, etc.) Mailing Address (Work)</p><p>Phone Email </p><p>Requestor Affiliation Please select your organization / agency type (select all that apply): Owner / Operator Tribal Government Trade Association Federal Government Public Utility University / Research Center State Government Law Enforcement Non-Profit Local Government Emergency Response Contractor / Consulting Firm </p><p>Other (Describe) </p><p>Supervisor Information Name Title Agency / Company Component (Department, Division, etc.) Phone Email </p><p>Basis for Request Please provide a justification for this request:</p><p>Additional Remarks A) If the requestor represents an owner / operator, identify the corresponding Federal and / or State regulatory agency (as applicable): </p><p>B) If the requestor does not represent an owner / operator, provide any additional information that may be helpful in describing the need for access. If possible, include contact information for those who may serve as reference (e.g., regulatory agency, DHS Protective Security Advisor, etc). </p><p>Please complete all fields. Incomplete submittals may lead to significant delays in the processing of this application. Privacy Act Statement: </p><p>Authority: 44 U.S.C. § 3101 and 44 U.S.C. § 3534 authorize the collection of this information. </p><p>Purpose: DHS will use this information to create and manage user accounts, including user names and passwords, and grant user access to the Homeland Security Information Network-Critical Infrastructure (HSIN-CI) Dams Portal. </p><p>Routine Use: This information may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974. This includes using the information, as necessary and authorized by the routine uses published in DHS/ALL-004 - General Information Technology Access Account Records System (GITAARS) November 27, 2012, 77 Fed. Reg. 70,792.</p><p>Disclosure: Furnishing this information is voluntary; however failure to provide any of the information requested may result in your user account not being created or may delay or prevent you from accessing the HSIN-CI Dams Portal.</p><p>Please complete all fields. Incomplete submittals may lead to significant delays in the processing of this application.</p>