36C26318Q0576-003.pdf

Department of Veterans Affairs

VHA Service Center Personnel Security 6100 Oak Tree Blvd #500 Independence, OH 44131

VSCSecurity@va.gov

PIV SPONSORSHIP FORM

CONTRACTOR EMPLOYEE INFORMATION

* All fields are mandatory *

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)

E Gender:

F Race:

G Height:

H Weight:

I Eye Color:

J Hair Color:

K Place of Birth (City, State, Country):

L Phone Number:

M Title of Contract:

N Prime Contractor:

O Position Title:

P Contractor Company Name:

Q Company Address: