Attachment FM1A_Contract Security Service Request.pdf
PDF 129 KB Posted
- Solicitation number
- 36C26124R0058
About this file
This document is a Contract Security Services Request Form for the Department of Veterans Affairs (VA). It provides details for a federal contract opportunity related to security services.
The key details include the contract information such as the VA Contracting Officer, Contract End Date, RPO Region, VISN & Station Number, and Purchase/Task Order or Contract Number. The form also includes contractor position details such as the Investigation Level required and the Contract Company Name. The bulk of the form contains a table for listing the Contractor Employee Information, including the employee's full legal name, social security number, email address, date of birth, and place of birth. A Contracting Officer signature is required to verify the existence of an official contract prior to processing the applicants for badging.
The related federal contract opportunity is for a task order to upgrade the administration and education entrance doors in Buildings 6 and 7, install protective canvas canopies, and construct a new concrete gutter at the Building 6 entrance for the VA Southern Nevada Health Care System. The solicitation is for contractors who were previously awarded a VISN 21 Multiple-Award Construction Contract. The project specifications and associated documents will be provided in the Task Order Bid Request.
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Text version
CONTRACT INFORMATION
Department of Veterans Affairs VHA 106A WMC HROO PerSecContractor Team
CONTRACT SECURITY SERVICES REQUEST
FORM # 1A
(Email to: VHAWMCPerSecContractor@va.gov)(Make sure it is encrypted or password protected)
VA Contracting Officer Name & Phone:
COR Name & Phone:
Contract End Date (Including Options):
RPO Region (East/West/Central):
VISN & Station#:
Purchase/Task Order or Contract Number:
Contractor Position Description:
Investigation Level (SAC/Tier 1/Tier 2/Tier 4):
Contract Company Name (Subcontractor):
Contract Company Address:
Contractor POC Name & Phone:
Contractor POC Email:
Contracting Officer Signature:
***This signature verifies that an official contract is in place prior to processing the applicants for badging***
Contractor Employee Information
Employee Name (Full Legal Name) SSN Email Address D.O.B. Place of Birth
(City, State/Country)
*Please use Continuation Form # 1B for additional individuals*
Current as of January 2023
| Employee Name Full Legal NameRow1: |
| SSNRow1: |
| Email AddressRow1: |
| DOBRow1: |
| Place of Birth City StateCountryRow1: |
| Employee Name Full Legal NameRow2: |
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| Place of Birth City StateCountryRow2: |
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| Employee Name Full Legal NameRow11: |
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| Text2: |
| Text3: Mark S. Smith 702-791-9000 ext 14054 |
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| Text5: Central |
| Text6: 21 / 593 |
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| Text9: T1 |
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