Attachment 5 - Replace Elevators 200 200E - PIV Badge Template.pdf
PDF 289 KB Posted
- Attached to
- Z1DA--402-21-709 Replace Elevators 200 200E
- Solicitation number
- 36C24124R0051
About this file
This document is a PIV badge request template for the Department of Veterans Affairs (VA) Maine Healthcare System. It outlines the required information to be submitted when requesting a PIV badge, such as the applicant's name, address, contact information, and position details. The template indicates that all highlighted information must be provided, or a badge cannot be issued.
The related federal contract opportunity is for the replacement of elevators 200 and 200E at the VA Maine Health Care System (Togus VAMC). The solicitation number is 36C24124R0051, and the contract is for construction services to deliver a complete construction project. Interested contractors are instructed to refer to the attached statement of work and submit a proposal no later than June 3, 2024 at 1:00 PM to the specified email address.
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Text version
Project Name: Type of Badge Requested: PIV NON-PIV FLASH
Circle one
Departmentof Veterans Affairs
VA Maine Healthcare System
Police Department
1 VA Center 07B
Augusta, ME 04330
207 623-5796
Last Name First Name Middle
Physical Street Address City State and Zip Code
Social Security Number
Gender (M) (F)
Service Line or Company Name Company or Cell Phone Number
Date of Birth
Place of Birth Occupation Title
Personal email for activation of badge process
For Engineers to fill out:
Contract end date:
Service Line Official Date
All highlighted info must be submitted, or a badge cannot be issued
FOR TOG US POLICE USE ONLY
VISTA RECORDS:
DATE CHECKED BY RECORDS FOUND TYPE
VAPS RECORDS:
DATE CHECKED BY RECORDS FOUND TYPE
LOCAL RECORDS:
DATE CHECKED BY RECORDS FOUND TYPE
STATUS F YES NO ADVANCED TO HR
File details come from the government source that posted it. Updated .