The file's text, extracted by GovTribe without its formatting.
Department of Veterans Affairs VHA Service Center Personnel Security 6100 Oak Tree Blvd #500 Independence, OH 44131 VSCSecurity@va.gov
Contract Security Services Request Form #1a (Please see Instructional Form 1a for assistance in completing this form)
New Request Addition
Contractor Information
| A VA Contracting Officer Name & Phone: |
| C Contract End Date (Including Options): |
| D SAO Region (East/West/Central): |
| E Purchase/Task Order Number: |
| F Contractor Position Description: |
| M Station #: |
| G Investigation Level (SAC/Low/Moderate/High): |
| N Network Access (Y/N): |
| H Contract Company Name (Subcontractor): |
| I Contract Company Address: |
| J Contractor POC Name & Phone: |
L Contracting Officer Signature:
***This signature verifies that an official contract is in place prior to processing the applicants for badging***
Contractor Employee Information
(Full Legal Name)
| SSN |
| Email Address |
| D.O.B. |
| Place of Birth |
(City, State/Country)
*Please use Supplemental Form 1b for additional individuals
VHA Service Center Personnel Security 6100 Oak Tree Blvd #500 Independence, OH 44131 VSCSecurity@va.gov
Contractor/Employee Fingerprinting Request Form #2
SON: 955C / SOI: VA08 IPAC/OPAC: 3600.1200
(Please see Instructional Form #2a for assistance in completing this form)
** This form must be taken to the fingerprinting appointment **
Employee Information (please print)
| A Full Legal Name (First Middle Last): |
Facility Information
| G Method of Fingerprinting: |
| Electronically / Manually |
| H Date Card Mailed to OPM*: |
After fingerprints are captured, return this completed form to your CO/COR for submission to VSC
*If fingerprints are manually taken, please ensure the FD-258 Fingerprint Card is used and that it is mailed directly to OPM at the address below, with this form. All fields on the fingerprint card MUST be completed. Please refer to Instructional Form #2a for an example of a completed fingerprint card. OPM will destroy all cards with incomplete fields. Delivery confirmation is recommended.
OPM Fingerprinting/SAC Team 1137 Branchton Rd Boyers, PA 16020
6100 Oak Tree Blvd #500 Independence, OH 44131 VSCSecurity@va.gov
VHA Service Center PIV Sponsorship Form #3 (Please see Instruction Form #3a for assistance in completing this form)
Contractor / Employee Information
* All fields are mandatory except va.gov email *
| A Full Legal Name (First Middle Last): |
| B Date of Birth (MM/DD/YYYY): |
| C Social Security Number: |
| D Citizenship: |
| (US Citizen, Naturalized, Non-Citizen) |
| F Address of Assigned Duty Station: |
| N Place of Birth (City, State, Country): |
| P Contractor Company Name: |
6100 Oak Tree Blvd #500 Independence, OH 44131 VSCSecurity@va.gov
Contract Security Verification Request Supplemental Form #1b (This form is used only when extra space is needed for large rosters.)
(Please reference Instructional Form #1b for assistance in completing this form)
| A Contracting Officer Name & Phone: |
| D Contract Company Name (Subcontractor): |
| E Contractor POC Name & Phone: |
(Full Legal Name)
| SSN |
| Email Address |
| D.O.B. |
| Place of Birth |
(City, State/Country)
Revised Oct 2010 Revised Form April 2012 image1.emf
