S02 D.2.5 Self Certification of Continuous Service Form.pdf
PDF 318 KB Posted
- Attached to
- 36C25725Q0072 Virtual Pharmacy Service
- Solicitation number
- 36C25725Q0072_2
About this file
This is a Self Certification of Continuous Service Form issued by the Department of Veterans Affairs (VA) WMC-HROO Personnel Security Contractor Processing Team, revised June 16, 2022. The form requires individuals to certify their break in federal service status by selecting one of four options: no break in service, break less than 60 days, break between 60 days and two years (requiring submission of OF 306), or break greater than two years/never had federal employment.
The form defines federal employment as service in any branch of U.S. military (Active, Guard, or Reserve), federal government civilian employment, or work as a contractor/sub-contractor for the federal government. It includes fields for the individual's name, social security number, signature, and date, as well as a section for VHA Personnel Security/HR use to document current investigation status in PIPS, risk level assessment, and verification details. The document appears to be part of the contractor processing requirements for a Virtual Pharmacy Service opportunity at the VA facility in Amarillo, TX.
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Other files
| File | Type | Posted |
|---|---|---|
| S02 D.2 Background Investigation.docx | DOCX document | |
| S02 D.2.2 Contractor Request Form – Foreign National.pdf | ||
| S02 D.3 Experience Worksheet 36C25725Q0072.docx | DOCX document | |
| S02 RFQ 36C25725Q0072_1 Final.pdf | ||
| S02 D.2.4 OF306 Declaration for Federal Employment.pdf | ||
| S02 D.5 Contractor Certification Immigration and Nationality Act.docx | DOCX document | |
| S02 D.6 Organizational Conflicts of Interest.docx | DOCX document | |
| S02 D.4 Contractor Rules of Behavior.docx | DOCX document | |
| S02 D.2.1 WMC Contractor Request US Citizens Only.pdf | ||
| S02 D.2.3 WMC Fingerprint Request Form 2.pdf | ||
| S02 D.1 QASP PLAN After Hours Pharmacy.docx | DOCX document | |
| 36C25725Q0072_2.docx | DOCX document |
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Text version
Department of Veterans Affairs WMC-HROO Personnel Security Contractor Processing Team
Self Certification of Continuous Service
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:
VHA 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 or sub-contractor working for the federal government.
Self Certification of Continuous Service Form Revised June 16, 2022
Previous Versions are Obsolete
I hereby certify my break in service from my last federal employment is indicated by the block checked above.
| I have NOT had a break in service: Off |
| My break in service was less than 60 days: Off |
| My break in service was greater than 60 days but less than 2: Off |
| My break in service is greater than 2 years or I have never worked: Off |
| Print Name: |
| Social Security Number: |
| Date: |
| Current Investigation in PIPS: |
| Date_2: |
| Risk level of current position: |
| Verified by: |
File details come from the government source that posted it. Updated .