36C10X19Q0239-004.docx

D.1 ATTACHMENT A: VA CONTRACTOR BACKGROUND INVESTIGATION

REQUEST WORKSHEET

The following applicant is a Contract employee.

Please complete the following fields on all applicants who have access to VA facilities, systems or privacy data:

Station where applicant will work:

Station Name – City: Hines, State: Illinois, Station #: 578 Station to be billed for clearance:

Station Name – Edward Hines Jr. VA Hospital

Please complete the following fields on each Contract Employee:

Applicant Name:

Last: ____________________ First: __________________ Middle: _______________ SSN: ________________ DOB: ________________ Email: _____________________ Place of Birth: City: ________________ State: _____ Country: _______ Contractor Occupation: ________________________________

Do you have a clearance pending or completed with OPM? Yes: No:

If yes, what level? _________

Are you asking for a low risk clearance on a foreign national? Yes: No:

Type of Investigation requested:

BI (High Risk): MBI (Moderate Risk): NACI (Low Risk):

Is this a security upgrade to the contract you are currently working? Yes: No:

VA COR: ___________________ VA COR Phone: ________________ VA COR Email: ____________________ Complete Address: 1800 G Street NW City/State: Washington, DC Zip Code: 20006 Prime Contracting Company Name: __________________________________________ Prime Contracting Company POC: __________________________________________ POC Phone: _____________________ POC Email: ____________________________ Complete Address: _______________________________________________________ City/State: __________________________________ Zip Code: _________________

Contract Title: _____________________________________________ Call/Contract #: _______________________________________ Obligation #: _________________________________________

If you are a Sub, what is your Company Name? __________________________