ATTACH C - Background Investigation Worksheet.docx

The following applicant is a Contract employee.

Please complete the following fields on all applicants who have access to VA facilities, systems or privacy data:

Station where applicant will work:

Station Name – City: ____________________ State: _____ Station #: __________

Station to be billed for clearance:

Station Name – City: Washington State: DC Station #: 101

Please complete the following fields on each Contract Employee:

Applicant Name:

Last: ____________________ First: __________________ Middle: _______________ If none (NMN) SSN: ________________ DOB: ________________ Email: _____________________ Place of Birth: City: ________________ State: _____ Country: _______ Contractor Occupation: ________________________________

Do you have a clearance pending or completed with OPM? Yes: No:

If yes, what level? _________ Are you asking for a low-risk clearance on a foreign national? Yes: No:

Type of Investigation requested:

NACI (Limited Risk):

Is this a security upgrade to the contract you are currently working? Yes: No::

VA Sponsor: VA Sponsor Phone:

VA Sponsor Email Box:

Complete Address: 425 I Street, NW City/State: Washington, DC Zip Code: 20420

Contracting Company Name: _______________________________________________ Contracting Company POC: ________________________________________________ POC Phone: _____________________ POC Email: ____________________________ Complete Address: _______________________________________________________ City/State: __________________________________ Zip Code: _________________

If you are a Sub, who is the Prime Vendor? ____________________________________ Contract Title : _____________________________________________ Contract #: _______________________________________ Obligation #: _________________________________________