Attachment -PIV Badge Template.pdf

This is a badge request form used by the Department of Veterans Affairs Maine Healthcare System Police Department to process identification badges for personnel requiring facility access.

The form collects personal information including name, physical address, Social Security number, gender, date and place of birth, occupation title, and contact information. Applicants must select one of three badge types: PIV (Personal Identity Verification), NON-PIV, or FLASH. The form requires submission of a service line or company name, company or cell phone number, and a personal email for badge activation. For contractor personnel, engineers must provide contract end dates and obtain signatures from the service line official with an accompanying date. The form emphasizes that all highlighted information must be submitted or a badge cannot be issued. The second page contains a police use section for background verification, including checkboxes for VISTA records, VAPS records, and local records checks with fields to document the date checked, checking officer, records found, and record type. A final status section indicates whether records resulted in a yes/no finding and whether the applicant was advanced to human resources for further processing. The form is administered through the VA Maine Healthcare System Police Department located at 1 VA Center 07B, Augusta, ME 04330.