SAC FORM - NEW 4.pdf
PDF 248 KB Posted
- Solicitation number
- 36C24726R0028
About this file
This is a VA Fingerprint Request Form used to initiate fingerprinting and background clearance procedures for individuals requiring access to VA facilities and systems.
The form requires applicants to select one of six categories: Employee, Contractor, Health Professions Trainee (VHA intern, resident, fellow, student), Affiliate, Volunteer, or Other. Applicants must provide complete personal identification information including legal name, Social Security Number, date of birth, citizenship status, physical descriptors (gender, height, weight, hair color, eye color, race/ethnicity), and contact details. Applicants must bring two original identity source documents from the VA-approved ID Matrix. For contractors, the form requires company name and address/work email; for health professions trainees, school name and training program information must be provided. Additional required fields include VA work location, organizational affiliation (VHA, VBA, NCA, VACO, etc.), position title, fingerprint location and date, and whether the applicant previously held a VA PIV card. The form includes fields for length of service, access to VA systems (yes/no), start date, and end date. For courtesy prints requested at another facility, applicants must provide the facility name, SOI#, and SON#. Administrative fields for the submitting registrar, submitting adjudicator, and VA points of contact are also included on the form.
View the file
Other files
Show all 23
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Applicant Category: Check One
EMPLOYEE CONTRACTOR
HEALTH PROFESSONS TRAINEE
(VHA intern, resident, fellow, student)
AFFILIATE VOLUNTEER OTHER:
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 Organization (VHA, VBA, NCA, VACO, etc.
Contractors Only: Company Name Company Address/Work Email
Health Professions Trainees Only: School Name Training Program
FINGERPRINT LOCATION 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
FINGERPRINT REQUEST FORM
Bring with you two (2) original IDs (Identity Source Documents) from the list below https://www.oit.va.gov/programs/piv/_media/docs/IDMatrix.pdf
Complete all fields on this form to the best of your ability
Length of Service
Courtesy Prints for another Facility:
Facility: _______________________________________
SOI# _______________
SON# ______________
Submitting Registrar:_______________________________ Submitting Adjudicator:_____________________________
VA Point of Contact Name and Email
VA Point of Contact Name and Email
VA Point of Contact Name and Email
Access to VA Systems: YES NO (Circle One)
Start Date:____________________________
End Date:_____________________________
If other, please provide a https://www.oit.va.gov/programs/piv/_media/docs/IDMatrix.pdf VHAASHSetzeA Highlight
VHAASHSetzeA Highlight
VHAASHSetzeA Highlight
VHAASHSetzeA Highlight
VHAASHSetzeA Highlight
VHAASHSetzeA Highlight
VHAASHWoodP Highlight
VHACAVJacksA1 Text Box
VHACAVJacksA1 Text Box
| Name Last First Middle: |
| Other Names Used AKA Maiden Name: |
| SSN: |
| Position Title: |
| Phone: |
| Date of Birth mmddyyyy: |
| CityState of Birth City and Country of Birth if not born in the US: |
| EMail Address: |
| Country of Citizenship: |
| VA Work Location: |
| POCCOTRSponsorSupervisor: |
| POC Phone: |
| FINGERPRINT LOCATION: |
| FINGERPRINT DATE mmddyyyy: |
| HEIGHT inches: |
| WEIGHT US pounds: |
| HAIR COLOR: |
| EYE COLOR: |
| Contractor Company Name: |
| Affiliate/School Name: |
| Training Program: |
| Other Applicant Type: |
| Contractor Company Address: |
| Race/Ethnicity: [ ] |
| Employee: Off |
| Affiliate: Off |
| Contractor: Off |
| Volunteer: Off |
| Health Professions Trainee: Off |
| Other: Off |
| Dual Citizen?: [ ] |
| Gender: [ ] |
| PIV?: [ ] |
| Courtesy?: Off |
File details come from the government source that posted it. Updated .