1h. Contractor Badging - Fingerprint Request Form 2025.pdf

2025 ENGINEERING SERVICE

PROJECT PLANNING CONTRACTOR

FINGERPRINT REQUEST FORM

Bring with you two (2) original IDs (Identity Source Documents).

Complete all yellow highlighted fields on this form to the best of your ability

Applicant Category: Check One (APPLICATION RENEWABLE IN 182 DAYS)

EMPLOYEE ✔ CONTRACTOR

HEALTH PROFESSONS TRAINEE,

resident (VHA intern, fellow, student)

AFFILIATE

VOLUNTEER

OTHER/CONTRACTED

EMPLOYEE

ENTER YOUR NAME EXACTLY AS IT APPEARS ON IDs

Name: (Last, First, Middle)

Other Last Names Used

SSN (use of pseudo number is not permitted)

Position Title

Telephone #

Date of Birth: (mm/dd/yyyy)

City/State and Country of Birth

E-Mail Address

Country of Citizenship

Dual Citizen?

VA Work Location

Name of Sponsor: Sponsor Phone:

Contractors Only: Company Name

Company Address/Work Email

Contract Start Date

Name of Project COR

Project #

Project End Date

FINGERPRINT LOCATION

Edward Hines Jr VAMC

FINGERPRINT DATE (mm/dd/yyyy)

PREVIOUS VA PIV CARD HOLDER (Yes/No)

GENDER (M/F)

HEIGHT (inches)

WEIGHT (US pounds)

HAIR COLOR

EYE COLOR

RACE/ETHNICITY

Facility Name Location:

Hines – 578 VISN 12

Facility SOI # Facility SON #

Date Cleared Signature

Comments

Mikel Jones, mikel.jones@va.gov 708 202-8387 ext 21322

PSAC-VACO 430H

Identifying documents NOT

ACCEPTED by USAccess include, but are not limited to:

1. Student ID Cards (including public/state universities, as well as private universities)

2. Gun or Firearms permits

3. License to Carry

4. Hunting/Fishing permits

5. Facility Badge

6. Temporary driver’s licenses

7. Selective service card

8. Company ID Card

9. Foreign Driver’s License (other than Canada)

10. Library Card

11. Temporary PIV Card

12. Marriage license

Primary Forms of Identification (Acceptable

Documents)

1. U.S. Passport or a U.S. Passport Card

2. Permanent Resident Card or an Alien Registration Receipt Card (Form I-

551)

3. Foreign passport

4. Employment Authorization Document that contains a photograph (Form I-

766)

5. Driver's license or an ID card issued by a state or possession of the United

States provided it contains a photograph

6. U.S. Military ID card

7. U.S. Military dependent's ID card; or

8. PIV Card.

Issue No. 20-

USAccess Deployment Bulletin

USAccess Identity Proofing Source Documents

Week of December 28, 2020

Email CM PMO

Weekly Bulletin Archive

Click here to Unsubscribe

Identifying Source

Documents Not Accepted for USAccess is Coming… Are You Ready?

Issue No. 20-45

USAccess Enrollment and Identity Proofing Documents

Secondary Forms of Identification (Acceptable

Documents)

1. U.S. Social Security Card issued by the Social Security Administration.

Laminated SSA cards cannot be used without Security Officer approval.

2. Original or certified copy of a birth certificate issued by a state, county, municipal authority, possession, or outlying possession of the United

States bearing an official seal

3. ID card issued by a federal, state, or local government agency or entity, provided it contains a photograph. EXCEPTIONS APPLY

4. Voter's registration card; 13. Reentry Permit (Form I-327)

5. U.S. Coast Guard Merchant Mariner Card

6. Certificate of U.S. Citizenship (Form N-560 or N-561)

7. Certificate of Naturalization (Form N-550 or N-570)

8. U.S. Citizen ID Card (Form I-197)

9. Identification Card for Use of Resident Citizen in the United States (Form I-

179)

10. Certification of Birth Abroad or Certification of Report of Birth issued by the

Department of State (Form FS545 or Form DS-1350)

11. Temporary Resident Card (Form I-688)

12. Employment Authorization Card (Form I-688A)

13. Reentry Permit (Form I-327)

14. Refugee Travel Document (Form I-571)

15. Employment authorization document issued by Department of Homeland

Security (DHS)

16. Employment Authorization Document issued by DHS with photograph

(Form I-688B)

17. Driver's license issued by a Canadian government entity

18. Native American tribal document.

The following rules apply to all presented identity source documents:

• All documents must be in their original forms - no photocopies other than a certified copy of birth certificate bearing an official seal.

• Expired or canceled identity documents are not a cceptable.

• All Primary forms of ID contain an expiration date;

however, some Secondary forms of ID do not. Not having an expiration date does not make a

Secondary ID Source unacceptable. Secondary forms of ID without an expiration date can be accepted.

• Up dating or replacing identity source documents is n o t required after successfully completing the id entity proofing process.

• If any of the identity source documents presented for identity proofing bear different names, then evidence of a formal name change must be provided linking the names. For example, a married woman with a current driver’s license and birth certificate can provide a marriage license.

Photos are required for all forms of primary identification documents.

mailto:vacohspd12pmo@va.gov http://vaww.oicam.va.gov/pscm/credential-management/communications/ mailto:vacohspd12pmo@va.gov?subject=Unsubscribe VHAHINDoyleL Text Box Real ID required

VHAHINDoyleL Text Box Real ID required

Form Approved:

OMB No. 3206-0182 Declaration for Federal Employment*

(*This form may also be used to assess fitness for federal contract employment)

Instructions The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. Most applicants are asked to complete this form after a tentative offer of employment has been made; however, depending on your position, you may be asked to complete this form earlier during the hiring process. Follow instructions that the agency provides. Before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").

Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

General Information

1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER 3a. PLACE OF BIRTH (Include city and state or country)

3b. ARE YOU A U.S. CITIZEN?

YES NO (If "NO", provide country of citizenship)

4. DATE OF BIRTH (MM / DD / YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc.) 6. PHONE NUMBERS (Include area codes)

Day

Night

Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Were you born a male after December 31, 1959? YES NO (If "NO", proceed to 8.)

7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) in item 16.

(*This form may also be used to assess fitness for federal contract employment)

Military Service

8. Have you ever served in the United States military? YES (If "YES", provide information below) NO

If your only active duty was training in the Reserves or National Guard, answer "NO.”

If you answered "YES," list the branch, dates, and type of discharge for all active duty.

Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge

Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?

(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

YES NO

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

YES NO

11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the charges, place of occurrence, and the name and address of the police department or court involved.

YES NO

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

YES NO

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

YES NO

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

(*This form may also be used to assess fitness for federal contract employment)

Additional Questions

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?

(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother, and half-sister.) If "YES," use item 16 to provide the relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relativeworks.

YES NO

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

YES NO

Continuation Space / Agency Optional Questions

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).

Certifications / Additional Questions APPLICANT: If you are applying for a position and received a tentative/conditional job offer or have not yet been selected, carefully review your answers on this form and any attached sheets.

APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions.

When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith. I understand that a false or fraudulent answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.

17a. Applicant's Signature: Date:

(MM / DD / YYYY)

17b. Appointee's Signature: Date:

(MM / DD / YYYY)

18. Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? Date:

(MM / DD / YYYY)

18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?

YES NO DO NOT KNOW

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

YES NO DO NOT KNOW

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

Appointing Officer:

Enter Date of Appointment or Conversion

MM / DD / YYYY

DEPARTMENT OF VETERANS AFFAIRS

PERSONNEL SECURITY ADJUDICATION CENTER

Self Certification of Continuous Service

I hereby certify my break in service from my last federal employment is indicated by the block checked below.

I have NOT had a break in service.

My break in service was less than 60 days.

My break in service was greater than 60 days, but less than two (2) years. (You are required to submit the OF 306, Declaration for Federal

Employment, with this form.)

My break in service is greater than two (2) years; or I have never had federal employment as defined above.

Print Name: Social Security Number:

Signature: Date:

VA Personnel Security/HR Use Only:

Current Investigation in PIPS: Date:

Risk level of current position: Verified by:

(Check One)

Federal employment is defined as any branch of the United States military (Active, Guard or Reserve), federal government civilian employee (any federal government agency), or a contractor working for the federal government.

Self Certification of Continuous Service Form Revised February 28, 2020

Previous Versions are Obsolete