Attachment 7d - VSC - Self Cert.pdf
PDF 102 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 self-certification form and notice of a federal contract opportunity. The self-certification form is for verifying an applicant's previous federal employment history and break in service.
The related federal contract opportunity is a solicitation notice for primary care clinic services for veterans in Cookeville, Tennessee and Roane County, Tennessee. The Department of Veterans Affairs intends to award an indefinite-delivery, indefinite-quantity contract for operating a community-based outpatient clinic in the specified locations. Services must be provided in a private hospital, office, or clinic environment. The contract type will be IDIQ with the opportunity for multiple awards. The solicitation is expected to be released on or around June 4, 2020 and will be posted on SAM.gov. The applicable NAICS code is 621498 and size standard is $22 million. The selection process will follow FAR Part 12 and 15 procedures.
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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 .