36C26319R0036-006.pdf

01 00 00 – Appendix B

01 00 00 - Appendix B - 1 of 2

NWIHCS VA POLICE SERVICE

FINGERPRINT REQUEST FORM

NAME (Last, First, Middle):

SOCIAL SECURITY NUMBER:

DATE OF BIRTH (YEAR/MONTH/DAY):

ALIAS (MAIDEN NAME):

GENDER: RACE/ETHNIC BACKGROUND:

EYE COLOR: HAIR COLOR:

HEIGHT: Feet: Inch: WEIGHT: Lbs:

PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)

CURRENT STREET ADDRESS:

CITY, STATE, POSTAL CODE:

CITIZENSHIP:

OCCUPATION:

EMPLOYER / SCHOOL AFFILIATION

AGENCY USE ONLY BELOW THIS LINE

TO BE COMPLETED BY HUMAN RESOURCES OR SPONSORING SERVICE

INDIVIDUAL’S VA STATUS:

FULL TIME VA EMPLOYEE PART TIME VA EMPLOYEE WITH OUT COMPENSATION (WOC)

AFFILIATING TRAINEE (STUDENT) AFFILIATING FACULTY CONTRACT EMPLOYEE

ASSIGNMENT OVER 120 DAYS YES NO

PROVIDES DIRECT PATIENT CARE YES NO

COMPUTER ACCESS REQUIRED YES NO

VA POLICE USE ONLY

IDENTITY VERIFICATION

DRIVERS LICENSE NUMBER: STATE OF ISSUE:

OR

PASSPORT NUMBER: COUNTRY OF ORIGIN:

FINGERPRINTS CONDUCTED BY: DATE COMPLETED:

The VA Police conducts fingerprinting in Omaha and Lincoln. Fingerprinting in Omaha is on a walk in basis Mondays-Fridays from 8:00 – 11:30 a.m. and Noon – 4:00 p.m. in the Main Hospital Room B804. For assistance or questions please call 995-5818.

CONTRACTOR PERSONNEL: FOR THE OMAHA AND LINCOLN FACILITIES SEND THE COMPLETED FORM TO CONTRACTING AT Building C, Room 101. FOR THE GRAND ISLAND FACILITY SEND THE COMPLETED FORM TO HR.

NOTICE: Access to this information is limited to AUTHORIZED PERSONS ONLY. Information may not be disclosed from this document unless permitted pursuant to 38 CFR 1.500 – 1.599. These records may not be altered or destroyed except as authorized by 38 CFR 1.579. This transmission is intended only for the use of the person or office to whom it is addressed and may contain information that is privileged, confidential, or protected by law. All others are hereby notified that receipt of this message does not waive any applicable privilege or exemption from disclosure and that any dissemination, distribution, or copying of this communication is prohibited. VA follows the requirements of the Privacy Act, which protects your personal information that VA maintains in “systems of records”. If you have received this communication in error, please notify us immediately at the telephone number shown above. Thank you.

01 00 00 – Appendix B

01 00 00 - Appendix B - 2 of 2

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