Attachment 6A_ Security_ServicesRequestForm.pdf

Revised Form January 2022

Department of Veterans Affairs WMC HROO ELR Shared Services Unit

Personnel Security WMC HROO VSC.Security@va.gov

CONTRACT SECURITY SERVICES REQUEST FORM #1A

(Please see Instructional Form 1a for assistance in completing this form)

Badge Required?

If checked, submit form 3 for contractor.

contractor

Type of Badge Required

CONTRACTOR INFORMATION

A VA Contracting Officer Name & Phone:

B COR Name & Phone:

C Contract End Date (Including Options):

D SAO Region or station (East/West/Central/776):

E Purchase/Task Order or Contract Number:

F Contractor Position Description: M Station #:

G Investigation Level (SAC/Tier 1/Tier 2/Tier 4): N Network Access (Y/N):

H Contract Company Name (Subcontractor):

I Contract Company Address:

J Contractor POC Name & Phone:

K Contractor POC Email:

L Contracting Officer Signature:

***This signature verifies that an official contract is in place prior to processing the applicants for badging***

O P Q R S

*Please use Supplemental Form 1b for additional individuals

CONTRACTOR EMPLOYEE INFORMATION

Employee Name (Full Legal Name) SSN Email Address D.O.B. Place of Birth

(City, State/Country)