ATT 4 PSIP FORM.pdf

PDF 30 KB Posted

Attached to
Professional Services (Dentist & Nurse Practitioner)
Solicitation number
W9127P21R0002
Issued by

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This document contains a federal contract solicitation and required forms for a professional services opportunity. The U.S. Army National Guard is seeking part-time professional services from a dentist and nurse practitioner, with performance taking place at a location in Estate Bethlehem, St. Croix, USVI from September 2021 through September 2026. The solicitation is set aside 100% for small businesses with a size standard of $8 million. Responses are due by September 7, 2021. The award will be a firm-fixed price contract for the base year plus four option years. Interested offerors must include completed representations and certifications with their responses.

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W9127P21R0002 RFP Prof Svcs FINAL.pdf PDF
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PSIP Required Information Worksheet

Personal Information:

SSN: _______________ (Only provide if Security Manager doesn’t have on file) Birth Date: ________________ (MM/DD/YYYY)

Rank/Prefix (SSG, SGT, Dr., Ms., Mrs., Mr.): ________ Last Name: ___________________ First Name: ____________ Middle Name: _________ Initial Only / No Middle Name (Type NMN) Postfix/Suffix (i.e.: II, III, Jr.): ______

Country of Birth: _________________ State of Birth: __________________ City of Birth: ___________________________

Investigation Information:

Role: Military / Civilian / Contractor (Circle the role that applies to you) Clearance Required: Secret / Top Secret /Suitability / PRP / None (Background Investigation) IT Level: I / II / III / None (Hint: Normal users are “III”)

Periodic Reinvestigation: Yes /No Reason for Investigation:_____________________________________________ Branch of Service: ARMY NATIONAL GUARD Expedite Request? Yes / No Justification: _______________________________________________________

Subject Contact Information:

Email Address (AKO preferred): _____________________________________ Secondary Email Address (Mandatory): _______________________________

Primary Phone: _________________ Comm / DSN / Overseas Secondary Phone: ________________ Comm / DSN / Overseas

Organization/Unit Name: VIRGIN ISLANDS ARMY NATIONAL GUARD Organization/Unit UIC: W7P4AA

Supervisor’s Contact Information:

Rank/Prefix: ______ First Name: ______________________ Last Name: ___________________ Title: ____________________________

E-mail Address: __________________________________________________ Phone: _________________ Comm / DSN / Overseas

SSN:
Birth Date:
RankPrefix SSG SGT Dr Ms Mrs Mr:
Last Name:
First Name:
Middle Name:
PostfixSuffix ie II III Jr:
Country of Birth:
State of Birth:
City of Birth:
Reason for Investigation:
Justification:
Email Address AKO preferred:
Secondary Email Address Mandatory:
Primary Phone:
Secondary Phone:
RankPrefix:
First Name_2:
Last Name_2:
Title:
Email Address:
Phone:

File details come from the government source that posted it. Updated .