Attachment 7d - VSC - Self Cert.pdf
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- Solicitation number
- 36C24920R0007
About this file
This document contains a solicitation notice for community-based outpatient clinic services. The Tennessee Valley Healthcare System is seeking proposals to operate CBOCs in Dover, TN and Hopkinsville, KY that will provide primary care services to veterans residing in the local areas. The indefinite-delivery, indefinite-quantity contracts to be awarded will place the clinics in a private hospital, office, or clinic environment. Service-disabled veteran owned and veteran owned small businesses must be registered in the VA Vet Biz and SAM databases. The NAICS code is 621498 with a $22 million size standard. Proposals must conform to the requirements of the forthcoming RFP, which will be issued on or around June 11, 2020 and posted to SAM. Questions should be directed to the point of contact via email only.
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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 .