Attachment WMC Form Ktr Employee Sponsor Request.pdf

Revised Form May 2023

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

CONTRACTOR/EMPLOYEE INFORMATION (PLEASE PRINT)

A Full Legal Name (First Middle Last):

B SSN Last Four:

C Contractor/Federal/Other:

NOTE: PLEASE ENSURE FULL NAME IS CORRECT AND CONFIRMED ON ID

VA FACILITY INFORMATION

D VAMC Name & Location:

E PIV Office Official :

F Date Fingerprinted:

(NEW>>> USAccess System Drop-down I.D Below)

WMC HROO PERSEC CONTRACTOR (VA08, 955C, 36001200)

Department of Veterans Affairs WMC HROO Personnel Security Contractor Team

CONTRACTOR/EMPLOYEE FINGERPRINTING REQUEST FORM #2

(PIV Legacy Systems - SON: 955C / SOI: VA08 IPAC/OPAC: 3600.1200)

VHACLEPanosA Highlight

Department of Veterans Affairs VHA 106A WMC HROO PerSecContractor Team

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 WMC.

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

NOTE: PLEASE ENSURE FULL NAME IS CORRECT AND CONFIRMED ON ID