Attachment 7d - VSC - Self Cert.pdf

PDF 102 KB Posted

Attached to
MSO-2020-CMP-0025 Bowling Green CBOC Federal contract opportunity
Solicitation number
36C24920R0048
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9

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Written by GovTribe AI ·

This document contains a self-certification form and details of a federal contract opportunity. The self-certification form is for continuous service verification for Department of Veterans Affairs personnel security clearance, requiring applicants to disclose any breaks in federal employment service of 60 days or more within the past two years.

The related federal contract opportunity is solicitation number 36C24920R0048 from the Department of Veterans Affairs Veterans Health Administration for construction services for the Bowling Green CBOC in Kentucky. The mid-tier size contract has an opportunity type of solicitation and is seeking construction services for the outpatient clinic. The solicitation is currently open and being administered through VISN 9.

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Other files for this federal contract opportunity

Other files attached to MSO-2020-CMP-0025 Bowling Green CBOC, newest first.
File Type Posted
36C24920R0048 0004.docx DOCX document
S06 - 36C24920R0048 0003 Extending Due Date.docx DOCX document
36C24920R0048 0002.docx DOCX document
36C24920R0048 0001.docx DOCX document
Attachment 7a - VSC - Security_CompletePacket.pdf PDF
Attachment 8b - OIT Design Guide templates.pdf PDF
PACT Space Module Design Guide.pdf PDF
Attachment 9 - WDOL 2015-4677 Rev 10 07-16-2019.pdf PDF
Attachment 18 - VISN-09 PBM CBOB Formulary.xlsx XLSX spreadsheet
Attachment 2 - Contractor Organizational Conflict of Interest.pdf PDF
Attachment 4 - Contractor Rules of Behavior 2019.pdf PDF
Attachment 12 - TVHS Memoradum 626-18-11-30 Anticoagalation management.pdf PDF
36C24920R0048.docx DOCX document
Attachment 16 - Management of the Impaired Practioner.pdf PDF
Attachment 7b - VSC - 306.pdf PDF
VA Form 0710 AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED UNDER THE FAIR CREDIT REPORTING ACT TITLE 15 SECTION 1681.pdf PDF
Infrastructure Standard for Telecommunications Spaces.pdf PDF
Attachment 10 - TVHS Memorandums - 626.pdf PDF
Attachment 6 - Deliverables-Reports Table - updating.pdf PDF
Attachment 11 - SB Goals FY 20.pdf PDF
IB 10-441 Enrollment Priority Group.pdf PDF
Attachment 17 - Past Performance Questionnaire.pdf PDF
Attachment 1 - Quality Assurance Surveillance Plan.docx DOCX document
Attachment 8 - CFM- CBOC Prototype Design.pdf PDF
Attachment 7 - VSC Security Package Flowchart.pdf PDF
Attachment 3 - Contractor Certification of Immigration and Nationality Act of 1952 - As amended.pdf PDF
Show all 26

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DEPARTMENT OF VETERANS AFFAIRS

SECURITY AND INVESTIGATIONS CENTER

Self Certification of Continuous Service

I hereby certify my break in service from my last federal employment is indicated by the block checked below.

I have NOT had a break in service.

My break in service was less than 60 days.

My break in service was greater than 60 days, but less than 2 years. (You are required to submit the OF 306, Declaration for

Federal Employment, with this form.)

My break in service is greater than 2 years or; I have never had employment through the federal government.

Print Name: Social Security Number:

Signature: Date:

VA Personnel Security/HR Use Only:

Current Investigation in PIPS: Date:

Risk level of current position: Verified by:

(Check One)

Federal employment is defined as any branch of the United States military (Active, Guard or Reserve), federal government civilian employee (any federal government agency), or a contractor working for the federal government.

Self Certification of Continuous Service Form Revised February 14, 2017

Previous Versions are Obsolete

I have NOT had a break in service: Off
My break in service was less than 60 days: Off
My break in service was greater than 60 days but less than 2: Off
My break in service is greater than 2 years or I have never worked: Off
Print Name:
Social Security Number:
Date:
Current Investigation in PIPS:
Date_2:
Risk level of current position:
Verified by:

File details come from the government source that posted it. Updated .