ATTACHMENT O - VSC Security Request Forms.pdf

Department of Veterans Affairs VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

VSC PERSONNEL SECURITY SERVICES OVERVIEW

The VHA Service Center Personnel Security Office offers a comprehensive service which ensures that contractor security requirements are met in accordance with OPM and federal regulations from initiation to completion.

Communication is maintained between the VSC, the contracting officer, the COR (COTR) and the contracting company point-of-contact at all times during the process. Due to PII concerns, no other personnel will be sent statuses from the VSC Security POC. If another entity requires this information, they must work through the CO, COR or Company POC.

This service includes the below:

Fingerprint adjudication:

o This involves a thorough background screening and adjudication of fingerprint along with any self declared information. After the results are confirmed or adjudicated, the National Criminal History Check (NCHC) Form will be sent to all contacts via email.

Existing investigations:

o Verifying existing investigation information and collecting the required documents for reciprocity.

The required documentation would include the OF306 Form and Self-Certification Form. These documents would be provided upon confirmation of investigation through the OPM Portal.

New investigations:

o Upon receipt of the Contract Security Services Request, our office will obtain and submit all required documents to request an investigation through Little Rock Security Investigations Center (SIC) and monitor the progress through completion.

PIV Badges:

o Our office can also manage and sponsor the PIV badges as required, as soon as the investigations are released from Little Rock SIC and scheduled by OPM.

To begin the process, please follow the below guidelines:

1. Upon notification of contract award, make appointments for fingerprinting. Ensure contractors bring Form #2 Fingerprint Request Form and 2 forms of ID to their appointment. .

2. Contracting officers, COR/COTRs complete and sign Form #1 in its entirety. All information is required. The packet will be rejected if this form is not complete or does not contain the CO signature.

3. Have employees complete all required documentation based on their risk level.

4. Submit complete packet to VSC.Security@va.gov encrypted. Incomplete packets will be rejected and returned. Complete packets will be assigned to a team member within 5 to 10-days dependent on workload. Subject line for the request submission email or fax cover sheet should be formatted as shown below. It is always our intention to work fast; we know its needed.

a. New Request Packet - Contracted Company VA000-00000

b. Status Request – Contracted Company VA000-00000 submitted on 00/00/0000

5. Do not submit new requests and additions more than once as this will result in duplicate assignments and wasted time. If you have not received a response to your request within 5-10 business days, send a status request to the mailbox using the above format.

6. If there is a change in the contracted personnel (resignation, declined appointment, etc) immediately notify the team member handling your request. The cancellation must be submitted via email.

7. Send any additions to the VSC Security team member that is assigned the contract. We cc the sender of this packet on that assignment so that you can work directly with that team member on all associated actions to include: reissuances, turnover, questions, concerns, statuses, etc. If the packet is already assigned and was not forwarded to the assigned member, we will reject that packet. This is so that we can assign the new contracts as fast as possible for you.

6100 Oak Tree Blvd #500 Independence, OH 44131

CONTRACT SECURITY SERVICES REQUEST - INSTRUCTIONAL FORM 1A

Purpose: The Contract Security Services Request is submitted to VSC to initiate the contract security verification process. By submitting this form, our office will ensure that each individual listed have been fingerprinted, the fingerprints are adjudicated if necessary, background investigations are initiated or existing background investigations are current and PIV badges are managed and sponsored. This form should be completed and signed by the contracting officer. Please refer to the instructions below when completing the Contract Security Services Request Form #1.

A

B

C

D

E

F

G

H

I

J

K

Contracting Officer & Phone: Please provide the post-award contracting officer handling this contract and their phone number.

COR (COTR) Name & Phone: Please list the Contracting Officer Representative (previously the Contracting Officer Technical Representative) and phone number. The COR is the liaison between the contracting officer and contracted company.

Contract End Date: Please list the date in which the contract ends including all options to extend (for PIV badge expiration).

SAO Region or 776: Please list the Service Area Office in which the contracting officer is associated with (East, West, Central or 776). If your contract is not coming from the SAO contracting group or station 776, then we would not service your contracts

Task Order Number: Please list the task order number (VA000-C00000). Our database is based on tracking contracts by station.

Should the task order number change at fiscal year end, please indicate on any future requests by listing the old task order number in parenthesis next to the new task number.

Contractor Position Description: Please provide a position title for all individuals (ex: physician, consultant, electrician).

Investigation Level: Please indicate the background security requirements as provided by the PDT (Position Description Automated Tool). This would include background screening or Fingerprint Only (SAC), low-level investigation (NACI) Tier 1, moderate-level investigation (MBI) Tier 2 and high-level investigation (BI) Tier 4. Please note that non-PIV badges (contract under 180-days) require at minimum a SAC, full PIV badges (over 180-days) require at minimum a NACI. If it is Tier 2 or 4, please provide a copy of the PDT to justify a higher level investigation.

Contract Company Name: Please provide the name of the contracting company that will be providing the work under the task order. Please provide subcontractors in parenthesis.

Contractor Address: Please provide the contracting company address. This information is required for the Little Rock SIC investigation request.

Contractor POC Name & Phone: Please provide the main point-of-contact for the contracting company and contact information.

This person may be contacted to provide additional information or documents in the process. All communication with this individual will include the contracting officer and COTR.

Contractor POC Email: Please provide the email address for the above mentioned point-of-contact. This email will be included in the investigation request submitted to Little Rock SIC.L Contracting Officer Signature: All requests must be signed by the contracting officer/specialist. This signature verifies that an official contract is in place prior to processing the applicants for investigation and badging.

M Station Number: Please indicate the facility station number where the work is being performed/facility to be billed.

N Network Access: Please indicate whether the individuals will be obtaining network access.

O Employee Name: Please provide the full legal name of the individuals working on this task order.

P SSN: Please provide complete social security numbers for all individuals listed.

Q Email Address: Please provide a valid email address for all individuals.

R DOB: Please provide date of birth for all individuals listed.

S Place of Birth: Please provide place of birth for all individuals listed, including city, state and country (if outside US). For foreign-born individuals, please provide proof of citizenship.

Revised Form November 2018

VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

CONTRACT SECURITY SERVICES REQUEST FORM #1A

(Please see Instructional Form 1a for assistance in completing this form)

Badge Required?

If checked, submit form 3 for contractor.

contractor

Type of Badge Required

CONTRACTOR INFORMATION

A VA Contracting Officer Name & Phone:

B COTR Name & Phone:

C Contract End Date (Including Options):

D SAO Region or station (East/West/Central/776):

E Purchase/Task Order or Contract Number:

F Contractor Position Description: M Station #:

G Investigation Level (SAC/Tier 1/Tier 2/Tier 4): N Network Access (Y/N):

H Contract Company Name (Subcontractor):

I Contract Company Address:

J Contractor POC Name & Phone:

K Contractor POC Email:

L Contracting Officer Signature:

***This signature verifies that an official contract is in place prior to processing the applicants for badging***

O P Q R S

*Please use Supplemental Form 1b for additional individuals

CONTRACTOR EMPLOYEE INFORMATION

Employee Name (Full Legal Name) SSN Email Address D.O.B. Place of Birth

(City, State/Country)

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

CONTRACTOR / EMPLOYEE FINGERPRINT REQUEST INSTRUCTIONAL FORM 2A

Purpose: The Contractor/Employee Fingerprint Request is to assist individuals in obtaining fingerprinting services from VA Facilities nationwide, on behalf of the VSC. This form is required by Little Rock SIC before a request for investigation can be submitted.

A Full Legal Name: Please provide full legal name of individual requiring fingerprints.

B SSN Last Four: Please provide the last four of the individual’s social security number.

C Contractor (Yes/No): Please indicate whether the individual is a contractor. Contracted employees are considered contractors.

D VAMC Location: Please provide the name and location of the VA Facility where the fingerprints were submitted.

E Station Number: Please provide the station number of the VA Facility where the fingerprints were submitted.

F Date Fingerprinted: Please provide the date that the fingerprints were submitted at the VA Facility.

G Method of Fingerprinting: Please indicate whether the fingerprints were submitted electronically or if manual fingerprints were submitted with ink and fingerprint card.

H Date Card Mail to OPM: If fingerprints were submitted manually, please provide the date the card was mailed to

IMPORTANT NOTE:

If fingerprints are manually taken, please send all cards to VSC directly.

*All fields on the fingerprint card MUST be completed or the card will be destroyed.

SON: VA08 SOI: 955C

IPAC/OPAC: 3600.1200

APPLICANT SIGNATURE

APPLICANT COMPLETE ADDRESS

DATE SIGNATURE OF OFFICIAL

EMPLOYER COMPLETE ADDRESS

CITIZENSHIP

SOC SEC #

LAST NAME FIRST NAME MIDDLE

SON: VA08 SOI: 955C

IPAC/OPAC: 3600.1200

VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

CONTRACTOR/EMPLOYEE FINGERPRINTING REQUEST FORM #2

SON: 955C / SOI: VA08 IPAC/OPAC: 3600.1200

(Please see Instructional Form #2a for assistance in completing this form)

** This form must be taken to the fingerprinting appointment **

EMPLOYEE INFORMATION (PLEASE PRINT)

A Full Legal Name (First Middle Last):

B SSN Last Four:

C Contractor/Federal/Other:

WE DO NOT REQUIRE THIS FORM BACK UNLESS THE PRINTS ARE MANUAL.

FACILITY INFORMATION

Electronically / Manually **Manual Prints will delay your prescreening**

D VAMC Name & Location:

E PIV Office Official :

F Date Fingerprinted:

G Method of Fingerprinting:

H Date Card Mailed to VSC:

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

PIV SPONSORSHIP INSTRUCTIONAL FORM 3A

Purpose: The PIV Sponsorship Form is used to complete the PIV badge application through the nationwide portal. All information is required to process a PIV badge. All fields are mandatory except the VA.GOV email address.

A Full Legal Name: Please provide full legal name of individual as shown on driver’s license or photo ID.

B Date of Birth: Please provide the date of birth of the individual.

C Social Security Number: Please provide the social security number of the individual.

D Citizenship: Please provide the citizenship of the individual. All foreign-born individuals will be required to submit proof of citizenship.

E Assigned Duty Station: Please provide the name of the individual’s assigned duty station.

F Address of Assigned Duty Station: Please provide the complete address of the assigned duty station.

G VA.GOV Email Address: Please provide the va.gov email address of the individual. If the individual has not had the email address established, or will not be obtaining an email address, please indicate pending or not applicable.

H Gender: Please provide gender of individual.

I Race: Please provide race of individual.

J Height: Please provide height of individual.

K Weight: Please provide weight of individual.

L Eye Color: Please provide eye color of individual.

M Hair Color: Please provide hair color of individual.

N Place of Birth: Please provide city, state and country of individual’s place of birth.

All foreign-born individuals will be required to provide proof of citizenship.

O Position Title: Please provide position title of individual.

P Contractor Company Name: Please provide the contracting company that the individual will be working under. If the individual is a VA employee, please indicate not applicable.

Q Contracting Company Address: Please provide the contracting company address. If the individual is a VA employee, please indicate not applicable.

VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

VHA SERVICE CENTER PIV SPONSORSHIP FORM #3

(Please see Instruction Form #3a for assistance in completing this form)

CONTRACTOR / EMPLOYEE INFORMATION

* All fields are mandatory except va.gov email *

(US Citizen, Naturalized, Non-Citizen)

A Full Legal Name (First Middle Last):

B Date of Birth (MM/DD/YYYY):

C Social Security Number:

D Citizenship:

E Assigned Duty Station:

F Address of Assigned Duty Station:

G VA.GOV Email Address:

H Gender:

I Race:

J Height:

K Weight:

L Eye Color:

M Hair Color:

N Place of Birth (City, State, Country):

O Position Title:

P Contractor Company Name:

Q Company Address:

Street Address, City, State, Zip Code

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

SECURITY VERIFICATION CONTINUATION

INSTRUCTIONAL FORM 1B

(This form is used only when extra space is needed for large rosters and must be submitted with a signed form 1a.)

A Contracting Officer Name & Phone: Please list the post-award contracting officer or specialist handling this task order and phone number.

B COTR Name & Phone: Please list the Contracting Officer Technical Representative and phone number. The COTR is the liaison between the contracting officer and contracted company.

C Task Order Number: Please list the task order number (VA000-C00000). Our database is based on tracking contracts by station. Should the task order number change at fiscal year end, please indicate this on any future request worksheets by listing the old task order number in parenthesis.

D Contract Company Name: Please provide the name of the contracting company that will be providing the work under the task order. Please provide subcontractors in parenthesis.

E Contractor POC Name & Phone: Please provide the main point-of-contact for the contracting company and contact information. This person may be contacted to provide additional information or documents in the process. All communication with this individual will include the contracting officer and COTR.

F Employee Name: Please provide the full legal name of the individuals working on this task order. If the individual is working on multiple task orders, please list them again as our database tracks contract statistics.

G SSN: Please provide complete social security numbers for all individuals listed.

H Email Address: Please provide a valid email address for all individuals. This email address will be provided for EQIP communication.

I DOB: Please provide date of birth for all individuals listed.

J Place of Birth: Please provide place of birth for all individuals listed, including city, state and country. For foreign-born individuals, please provide proof of citizenship.

VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

CONTRACT SECURITY VERIFICATION REQUEST SUPPLEMENTAL FORM

#1B

(This form is used only when extra space is needed for large rosters and must be submitted with a signed form 1a.)

A Contracting Officer Name & Phone:

B COTR Name & Phone:

C Task Order Number:

D Contract Company Name (Subcontractor):

E Contractor POC Name & Phone:

F G H I J Employee Name

(Full Legal Name) SSN Email Address D.O.B. Place of Birth (City, State/Country)

Declaration for Federal Employment* (*This form may also be used to assess fitness for federal contract employment)

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

Instructions The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. You may be asked to complete this form at any time during the hiring process. Follow instructions that the agency provides. If you are selected, before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").

Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

General Information

1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER

3a. PLACE OF BIRTH (Include city and state or country)

3b. ARE YOU A U.S. CITIZEN?

YES NO (If "NO", provide country of citizenship) ♦

4. DATE OF BIRTH (MM / DD / YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc.)

6. PHONE NUMBERS (Include area codes)

Day ♦ Night ♦

Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Were you born a male after December 31, 1959? YES NO (If "NO", proceed to 8.)

7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) in item 16.

Military Service

8. Have you ever served in the United States military? YES (If "YES", provide information below) NO

If your only active duty was training in the Reserves or National Guard, answer "NO.”

If you answered "YES," list the branch, dates, and type of discharge for all active duty.

Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge

Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?

(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the charges, place of occurrence, and the name and address of the police department or court involved.

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

YES NO

YES NO

YES NO

YES NO

YES NO

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

Additional Questions

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?

(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother, and half-sister.) If "YES," use item 16 to provide the relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relative works.

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

Continuation Space / Agency Optional Questions

YES NO

YES NO

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).

Certifications / Additional Questions APPLICANT: If you are applying for a position and received a tentative/conditional job offer or have not yet been selected, carefully review your answers on this form and any attached sheets.

APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions.

When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith. I understand that a false or fraudulent answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.

17a. Applicant's Signature: Date:

(MM / DD / YYYY)

17b. Appointee's Signature: Date:

(MM / DD / YYYY)

18. Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? Date:

(MM / DD / YYYY)

18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

YES NO DO NOT KNOW

YES NO DO NOT KNOW

Appointing Officer:

Enter Date of Appointment or Conversion

MM / DD / YYYY

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

AUTHORIZATION FOR RELEASE OF INFORMATION

PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)

STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE

I Authorize the Department of Veterans Affairs (VA), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.

The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows VA to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.

VA is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.

I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.

SIGNATURE OF EMPLOYEE (Sign in ink) TYPE OR PRINT LEGIBLY FULL NAME DATE SIGNED

OTHER NAMES USED HOME TELEPHONE NUMBER (Include Area Code)

CURRENT ADDRESS (Include Street, City, State, and ZIP Code)

VA FORM

OCT 2017 0710