Attachment 12 - Contractor PIV Instructions and Form.pdf

H o w t o G e t a ¥ A I D B a d g e

A resource for Applicants

I '""'^^tSponsored

Regardless of affiliation, everyone worlting within VA facilities or requiring access to VA information systems requires a credential, Tliis page provides the necessary information

Applicants need to successfui iy be issued a VA I D Badge.

C H E C K L I S T 0

• D ° have two forms of ID? (acceptable forms of ID Jisted on Form 1-9 and Identity

Documentation Criteria)

» Names must match on both documents

• Both documents must not be expired

D Are you Sponsored in the VA System?

«» Asl< your manager for more details n Have you scheduled an appointment with a badge offlce?

• 9 See the list of badge offlce locatinn.q tn find the^ H n c g c t - n p o

• You must bring two forms of ID with you to your appointment

» VACO ONLY: Online Appointment Sctieduler

D Do you know your responsibilities as a VA ID Badge holder?

» Read through the Applicant training to better understand your role and responsibility as a

VA ID Badge holder.

• "^^^^ minimum a completed and successfully adjudicated Special Agreement

Cfieck (SAC) - wliich includes a name and 10 fingerprint check - and an initiated

National Agency Check with Written Inquines (NACI) or higher background investigation. In addition, your VA email account must be established or in the process of being-established.

• employed with VA more than 6 months or more than 180 aggregate days in a one year period.

• Require access to VA facilities AND/OR information systems.

® Non-PIV card - You IWust:

" . Have at minimum a completed and successfully adjudicated Speciai Agreement

Check (SAC)- which includes a name and 10 fingerprint check.

• • employed with VA less than 6 months or less than 180 aggregate days in a one year period.

• f^equire access to VA facilities AND/OR information systems.

9 Have fingerprints taken.

8 Flash badge - You Must:

« Have at minimum a completed identity verification using one form of government-issued photo ID .

» Be employed with VA less than 6 months or less than 180 aggregate days in a one year period.

» Only require common physical access.

• Contact y o u r P I V Sponsor to initiate your PIV card request.

Your PIV Sponsor determines the type of credential vou need, approves your

•PIV card request, validates your identity and initiates your request m the PIV system.

W o r k w f t h y o u r Sponsor to complete the online application form.

The Registrar verifies your identity and verifies your background investigation status m the OfSce of Personnel Management (OPM) database. To proceed with issuing a PIV card, your Special Agreement Check (SAC) needs to be favorably adjudicated and your National Agency Check with Written Mquiries (NACI) or higher background investigation must be, at minimum, "hoitiated" m the OPM system.

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Form Approved: OMB No. 2900-0673 Respondent Burden: 5 Minutes

R E Q U E S T F O R P E R S O N A L IDENTITY VERIFICATION CARD

PRIVACY A C T STATEIWENT: VA is autiiorized to asic for tlie infomiation requested on this form by Homeland Securi^' Presidential Directive (HSPD)-12, and 31 USC 7701. The information and biometrics collected, collected as part ofthe Federal ideiititj'-proofing program under .HSPD-12 are used to veriî ' the personal identitj' of VA applicants for employment, employees, contractors, and affiliates (such as students, WOC employees, and others) prior to issuing a Department identification credential. The credentials themselves are to be used to authenticate electronic access requests from VA employees, contracfors, and affiliates issued a Departmeni identification credential to gain access to VA facilities and networks (where available) through digital access control systems, as well as to other federal govemment agency facilities and systems where permitted by law. The infonnation collected on this form is protected by the Privacy Act, 5 USC Section 552(a) and maintained under the authority of 38 USC Section 501 and 38 USC Sections 901-905 in VA system of records "Police and Security Records-VA (103VA07B)". VA may make a "routine use" disclosure ofthe information in this system of records for the routine uses listed in this system of records, including: civil or criminal law enforcement, constituent congressional communications initiated at your request, litigation or administrative proceedings in which the United States is a part)' or has an interest, the administration of VA programs, verification of identitj' and status, and personnel administration by Federal agencies. Failure to provide all ofthe requested information may result in VA being unable to process your request for a Personal Identitj' Verifiotion Card, or denial of issuance of a Personal Identity' Verification Card. Ifyou do not have a Personal Identitj' Verification Card, you may not be granted access to VA facilities or netsvorks, which could have an adverse impact on your application to become, or status as, a VA employee, contractor or affiliate where such access is required to perfomi your assigned duties or responsibilities.

PAPERWORK REDUCTION A C T NOTICE: The public reporting burden is approximately 5 minutes including time to review instruction, find the infonmation, and complete this form. Send comments regarding this burden estimate or any other aspect of this collection of infomiation, including suggestions for reducing this burden, to the VA Clearance Officer (005E3), 810 Vermont Avenue, Washington, DC 20420.

SECTION I - APPLICANT INFORMATION T \ - \ e. ivOV>o\e. Sex-±\Ov-^ A P P L I C A N T I N F O R I V I A T I O N (Completed by Applicant)

1. LEGAL NAME OF APPLICANT (Insert last, first, middle and suffix namoh. NICKNAME TO BE USED FOR APPLICANT (Insert last name and first name. If applicable)

3. DATE O F BIRTH (MM/DDA'YYY) 4. SOCIAL SECURITY NO. 5. HOME PHONE NUMBER (Include Area C<i<le) (Oplional)

6. HOME E-MAIL ADDRESS (Optional) 7. HOME ADDRESS

8. SIGNATURE O F APPLICANT 9. DATE SIGNED

SECTION II - SPONSOR VERIFICATION (Completed by Sponsor)

P A R T A - A P P L I C A N T E M P L O Y M E N T I N F O R I V I A T I O N (Completer! by Sponsor)

1. NAME AND ADDRESS OF FACILITY OR ASSIGNED DUTY STATION 2. NAME OF SPONSORING DEPARTMENT, SERVICE, OR SECTION, AND MAIL ROUTING

SYMBOL

3. CREDENTIALS/ORGANIZATIONAL TITLE (AKA Posilion'M Tille)

S. WORK PHONE NUMBER (If applicable)

4. COST CTR.

6. WORK E-MAIL ADDRESS

P A R T B - T Y P E . O F R E Q U E S T A N D E l V I P L O Y I V I E N T S T A T U S (Completed by Sponsor)

1. TYPE OF REQUEST

^ NEW ID • • RENEWAL REPLACEMENT ID r'Unmagerf'/.as/; CHANGE LEVEL OF ACCESS

2. TYPE OF CARD

r - , PERSONAL IDENTITY r - | (^oN-PIV) L J VERIFICATION (PIV) | _ j V A U N U I N r i v ^

3. TYPE OF ACCESS

• LOGICAL ACCESS fOomain) CU PHYSICAL ACCESS rCo,H;>fe/e f o r t

4. EMPLOYMENT STATUS

• VA EMPLOYEE CONTRACTOR • AFFILIATE (Specify) • TEMPORARY VA EMPLOYMENT

P A R T C - P H Y S I C A L S E C U R I T Y A C C E S S D A T A (Completed by Sponsor)

. SPECIAL SECURITY ACCESS REQUIRED

YES (ff'YES," Specify in !lem2) • N O

2. SPECIFY LOCATION OF SPECIAL

SECURITY (i.e. tower, bldg. no., etc)

3. IS APPUCANT A KEY EMERGENCY RESPONDER, CRITICAL

EMPLOYEE, OR NEITHER?

• EMERGENCY RESPONDER

• CRITICAL EMPLOYEE [ " j NEITHER

P A R T D - T Y P E O F - B A C K G R O U N D I N V E S T I G A T I O N F O R P O S I T I O N (Completed by Sponsor)

TYPE OF BACKGROUND INVESTIGATION FOR POSITION

SAC • NACI • SECRET • TOP SECRET • OTHER (Specify)

P A R T E - C O N T R A C T O R S , A F F I L I A T E S , A N D T E I V I P O R A R Y E l V I P L O Y I V I E N T I N F O R I V I A T I O N (Completed by Sponsor) '

EMPLOYMENT EXPIRATION DATE /CONTRACT END DATE

(MM/DD/YYYY)(For Contractors, Affiliates, and Temporary Employment)

NAME OF CONTRACTING OFFICER TECH. REPR. (If applicable)

2. NAME OF FIRM OR COMPANY (If applicable)

A. NAME OF RESPONSIBLE VA ORGANIZATION 5. MAIL ROUTING SYM,

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P A R T F - S P O N S O R A U T H O R I Z A T I O N A N D C E R T I F I C A T I O N (Completed by Sponsor)

CERTIFICATION; I Certify tmder penalt)' of perjurj' that the infonnation in Section II is true and correct.

1. NAME OF SPONSOR 2. SPONSOR CREDENTIALS/ORGANIZATIONAL TITLE

3. CERTIFICATE NUMBER (J.mmlby I'ClMaiiagar orKeglstrar) 4. SIGNATURE OF SPONSOR 5. DATE SIGNED (MM'DDm'YY)

6. WORK ADDRESS 7. NAME OF SPONSOR'S DEPARTMENT, SERVICE, OR SECTION 6. WORK ADDRESS

8. WORK PHONE NUMBER (Include Area Coda)

6. WORK ADDRESS

9. WORK E-MAIL ADDRESS •

SECTION lil • APPLICANT IDENTITY VERIFICATION (Completed by Registrar)

INSTRUCTIONS: To be completed and signed by Registrar at the time of proofing. Review Section I - Applicant Information, ahd Section I I - Sponsor Verification, assuring that information has been filled out correctly and signed accordingly. The identification mtist follow these guidelines:

• Applicant must present tvvo ( 2 ) forms of identification from the Accepted Identification Documentation List.

• The names on the identification must match exactly (If one ID has a full middle name, and the other has a middle initial, then the initial must match).

• One State or Federal ID must contain a photograph, e Both IDs must be original documents. • Both IDs must be currently valid, not expired.

» Verify 'that the applicant has background informaition on file. I f no evidence of a SAC exists, then capture fingerprint data and process accordingly.

P A R T A - B A C K G R O U N D C H E C K

1 . T Y P E O F B A C K G R O U N D C H E C K

S A C (Fingerprint Checit) N A C I O T H E R (Specify)

1 A . D A T E I N I T I A T E D B A C K G R O U N D C H E C K

(MM/DD/YYYY)

1 B . D A T E A D J U D I C A T E D B A C K G R O U N D C H E C K

(MM/DD//YYY)

2. FINGERPRINTS CAPTURE REQUIRED?

Q Y E S g ] m (If'NO." proceed 101'ariB)

3. SEX • 4. R A C E 6. H E I G H T 8. W E I G H T 7. E Y E S 8 . H A I R 9. PLAGE O F B I R T H

10. NOTICABLE SCARS AND TATTOOS

P A R T B - P H O T O G R A P H I C I D E N T I F I C A T I O N N U I V I B E R 1

1. EXACT NAME LISTED ON PHOTO ID 2. DOCUMENT IDENTIFICATION NUMBER 3. EXPIRATION DATE (MM/DDA'YYY)

4. DOCUMENT TYPE 5. ISSUANCE DATE (MM/DD//YYY) 6. ISSUING AUTHORITY

P A R T C - I D E N T I F I C A T I O N N U I V I B E R 2

1. EXACT NAME USTED ON ID 2. DOCUMENT IDENTIFICATION NUMBER 3. EXPIRATION DATE (MM/DDA'YYY)

4. DOCUMENT TYPE 5. ISSUANCE DATE (MM/DD//YYY) 6. ISSUING AUTHORITY

P A R T D - R E G I S T R A R I N F O R I V I A T I O N A N D S I G N A T U R E

1. WORK ADDRESS 2. PRINTED NAME OF REGISTRAR 1. WORK ADDRESS

3. NAME OF DEPARTMENT, SERVICE, OR SECTION

1. WORK ADDRESS

4. WORK PHONE NUMBER (Include Area Code) 5. WORK E-MAIL ADDRESS

6. DATE APPLICANT INITIATED BACKGROUND INVESTIGATION 7. APPLICANT 'S REQUEST FOR PERSONAL IDENTITY VERIFICATION CARD

ACTION T A K E N :

• APPROVED • DENIED

CERTIFICATION: I certify that under penalt)' of perjurj' that I have examined the documents presented by fhe above named person, and that the above listed documents appear to be genuine and to relate to the person named.

8. SIGNATURE OF REGISTRAR 9. DATE SIGNED (AdM'DD.'i'm)

VA FORM 0711, OCT 2006 (RS), PAGE 2 OF 3 • . ' AdobeFormsDesigner

SECTION IV - PERSONAL IDENTITY VERIFICATION CARD ACCEPTANCE

P A R T A - C A R D lNFORNtATlON(Compleleil by Jssiier)

1. NtVV PIV UKtDENTIAL SERIAL NUMBER 2, OLD ACCESS ID CARD NUMBER 3, EXPIRATION DATE (MV/.'DDmryj

P A R T B - P E R S O N A L I D E N T I T Y V E R I F I C A T I O N C A R D A C C E P T A N C E fCoim dieted bv Applicant).

A C K N O W L E D G E M E N T : I acknowledge receiving my identity credential and w i l l comply w i t h the fo l lowing obligations:

® I have been provided training on the responsibilities associated w i t h receipt o f t h i s Personal Identity Verif icat ion Card, ® 1 w i l l use m y Personal Identity Verif icat ion card in accordance w i t h the training I have been provided,-

(JEJ<1 J1<ICATI0N: I certifs'that T h a v R rpaH n n r l n o r p A f n Hi» nkr^^.o ofot-..«,,^»^,, + u „ t T i • . - j , . _ , ' •

1 . PRINTED NAME OF APPLICANT

P A R T C - P U B U C K E Y IN

..v̂ l i t v n u w r v , , aLau^. i in„i i i :> anu mal i jiavc icccjveu my cara, 2, APPLICANT SIGNATURE OF ACCEPTANCE

F O R M A T I O N ( P K I ) C E R T I F I C A T E A C C E P T A N C E (Con

3, DATE SIGNED (MM/DD.n'YYY) ipleted by Applicant)

Y o u have been authorized to receive one or more private and public key pairs and associated certificates, A private key enables you to digital ly sign documents and mess ges and ident i fy yourself to gam access to information systems and facili t ies. You may have another private key to deciypt data such as e3pted rerages . ^ f ' - " ' ^ V A w i l l use public keys associated w i t h your private keys to ver i fy your digital'signature, or to verTfyTOUHS

, or to encrypt data sent to vou . The certificates and nrivate kp.vs will hp i « „ p ^ o t,,i,p„ . 1 r, -> . . h e . v Z Z l T , T ' f r " " ' ' " ^ P^''^^'^ êys to ver i fy your digital signature, or to ver fy your identit)- JentiW V e r f f r a l n C a t ' t p f T ' ' ' '^T' or to enc^pt data sent to you. The certificates and private keys will be i s s u e l o n a Token, for example your Personal

V A 5 J n V A 1 I ^""^ P^^^te keys on your token are government property. Users are authorized to use the certificates w i t h i n V A , as well as whi le conduchng busmess wi th other Federal, state, and Local Government agencies, use me certiiicates w i t l i i n

A C I C N O W L E D G E M E N T O F R E S P O N S I B I L I T I E S

^ m ^ R S T o f T c t S ? ^PP''^^"""" this certificate is accurate, current, and complete. I f this infomiat ion changes, I will n o t i f y

• I wi l l use m y certificate(s) and private key(s) for of f ic ia l purposes only;

® i w l i i l ' ^ r ' ' ' ^ ' -M ' ^^f^'^^^^ Practices Statement for selecting a Personal Identif ication Number (PIN) or other required method for controll ing access to mv private keys and will not disclose same to anyone, leave if where i t migh t be observed, nor wr i te i t on the token itself; controll ing access to my

• I understand that digital signatures applied using m y digital certificates cany the same legal obligation as my physically signing the document;

• Lcov'i^t^^^^^^^^^ SheSdTbrreTreT^^^^^^^^ ™ ^"^ '^^ ^ " - ' ^ ' ^ - ' > ' P « - ^^^^ ^ave been provided to th.key

• c S a & h o r i ? , T S t l ' ^ ^ : ^ ^ t ^ . ^ r ^'"^ ™ " ' °

L I A B I L I T Y

JeSe'^aTertTfiir vfLTihIPf ' *°™l * e P K I certificates the key recoveiy process, or a Certification Authori ty 's (CA) detemiination to terminate or certificate Sued S a ^ A C A ' ° ° ' ' = P = " ^ ' . P""it''v<= damages, arising out o f or relating to any

G O V E R N M E N T L A W

V A Public K e y Certificates shall be governed by the laws o f t h e United States o f America, CERTIFICATION: I c e r t i f y t h a t I have read and agree t o the above statements and tha t I have rece ived m y Pia c e r t i f i ca t e ( s ) .

| 1 . FULL LEGAL NAME OF APPLICANT 2. SIGNATURE OF ACCEPTANCE

1. WORK ADDRESS

SECTION V - ISSUER (Completed by Issuer)

3. DATE SIGNED (Am/DD.fYYYY)

2. PRINTED.NAME OF ISSUER

3. NAME OF DEPARTMENT, SERVICE, OR SECTION

4. WORK PHONE NUMBER (liiciude Area Code) 5. WORK E-MAIL ADDRESS

CERTIFICATION: I c e r t i f y unde r penal ty o f p e r j u r j ' , t h a t I have m o n i t o r e d the i d e n t i f y v e r i f i c a t i o n o f t h e person above i n accordance w i t h a p p l i c a b l e i d e n t i f y p r o o f m g processes and have wi tnessed t h a t p e r s o n s ign t h i s f o r m .

6. SIGNATURE OF ISSUER

7. DATE SIGNED (MM-'DD.mY)

VA FORM 0711, OCT 2006 (RS), PAGE 3 OF 3