Contractor_Clearance_Form-KM.pdf

United States Marshals Service

Eastern District of Virginia

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Any building tenant scheduling contractor services to be performed inside U.S. Courthouse space must complete this form in its entirety and submit to the local U.S. Marshals Service office a minimum of twenty-four (24) hours in advance of the contractor start date.

GSA / U.S. Courthouse Tenant Contact Information

Requesting Agency:

Requestor (Name):

Office Telephone Number: Mobile Phone:

Contractor / Vendor Information

Full Name (Last, First,Middle): Gender: Male Female

Date of Birth (mm/dd/yyyy): Soc. Sec. Number:

Place of Birth:

Current Home Address:

City: State: Zip Code:

Race:

Company Name:

*Contractor/Vendor must be escorted at all times in non-public areas of the courthouse*

Results of Inquiry

Pass: Fail:

US Courthouse Tenant

/ GSA

Approver Signature: