Attachment 7c - VSC - VA0710.pdf
PDF 85 KB Posted
- Attached to
- Q201--MSO-2020-CMP-0029 Capitated CBOC - Cookeville and Roane Cnty - Long-Term Base + 6 options
- Solicitation number
- 36C24920R0060
About this file
This document contains a federal contract opportunity solicitation for Community Based Outpatient Clinic services in Cookeville, Tennessee and Roane County, Tennessee. The Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9 will award an indefinite-delivery, indefinite-quantity contract to offerors who can successfully operate a CBOC in the desired locations. Services must be provided in a private hospital, office, or clinic environment to local Veterans. Preference will be given to service-disabled veteran owned and veteran owned small businesses. The solicitation number is 36C24920R0060 and is expected to be released on or around June 4, 2020 on the System for Award Management website. Questions regarding the solicitation should be directed to Darryl Scherer by email only. Award will be made to the offeror whose proposal is most advantageous to the government considering responsiveness and conformance with the solicitation requirements.
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Text version
AUTHORIZATION FOR RELEASE OF INFORMATION
PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)
STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE
I Authorize the Department of Veterans Affairs (VA), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.
The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows VA to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.
VA is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.
I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.
SIGNATURE OF EMPLOYEE (Sign in ink) TYPE OR PRINT LEGIBLY FULL NAME DATE SIGNED
OTHER NAMES USED HOME TELEPHONE NUMBER (Include Area Code)
CURRENT ADDRESS (Include Street, City, State, and ZIP Code)
VA FORM
OCT 2017 0710
..\logos\VA Form Bar-04(NEW LOGO).jpg Department of Veterans Affairs logo
AUTHORIZATION FOR RELEASE OF INFORMATION
PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)
AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 16 81)
STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE
I Authorize the Department of Veterans Affairs (VA), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.
The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows VA to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.
VA is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.
I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.
SIGNATURE OF EMPLOYEE (Sign in ink)
TYPE OR PRINT LEGIBLY FULL NAME
DATE SIGNED
OTHER NAMES USED
HOME TELEPHONE NUMBER (Include Area Code) CURRENT ADDRESS (Include Street, City, State, and ZIP Code)
VA FORM
OCT 2017
V A Form 0 7 1 0, OCTOBER 2017 VA Form 0710, AUTHORIZATION FOR RELEASE OF INFORMATION
PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)
0710, Authorization, Release, Information, Protected, Fair, Credit, Reporting, Act Missie Vaccaro-Palomaki
MAY 1998
OCTOBER 2017
Trish Moore (07)
STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE.
I Authorize the Department of Veterans Affairs (V A), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.
The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows V A to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.
V A is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.
I understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.
Signature of Employee (Sign in ink):
| TYPE OR PRINT LEGIBLY FULL NAME: |
| DATE SIGNED: |
| OTHER NAMES USED: |
| HOME TELEPHONE NUMBER (Include Area Code): |
| CURRENT ADDRESS (Include Street, City, State, and ZIP Code): |
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