Attachment 7d - VSC - Self Cert.pdf
PDF 102 KB Posted
- Attached to
- Q201--MSO-2020-CMP-0028 Capitated CBOC Maury County & McMinnville Base plus 6 option periods
- Solicitation number
- 36C24920R0010
About this file
This document contains a federal contract opportunity notice for community-based outpatient clinic services. The Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9 is seeking proposals to operate CBOCs in McMinnville, TN and Maury County, TN providing primary care services to veterans. The contract will be an indefinite-delivery, indefinite-quantity agreement awarded to the offeror with the most competitive proposal meeting the requirements. Offerors must be registered in the VA VetBiz and SAM databases. The anticipated release date for the solicitation is May 28, 2020 and it will be posted at beta.sam.gov. Questions must be submitted in writing to the point of contact by the specified date.
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Text version
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 .