Contractor Background Investigation Request Form (May 2019).pdf

PDF 95 KB Posted

Attached to
Replace Linear Accelerator at Greater Los Angeles VAHCS Federal contract opportunity
Solicitation number
36C25821B0004
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 22

About this file

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This document contains a federal contract opportunity solicitation and a related contractor background investigation request form. The solicitation is for replacing a linear accelerator at the Greater Los Angeles VA Healthcare System for the Department of Veterans Affairs. The contractor shall demolish the existing linear accelerator, coordinate installation of a new linear accelerator and associated equipment with the provider, and perform other construction and renovation work. This includes renovating rooms, adding a mechanical and server room, replacing ceiling and flooring, rewiring, installing new HVAC, ductwork, casework and finishes. The contractor must also provide structural supports, electrical power requirements, controls and security systems. The background investigation request form is used by a VA organization to request background investigations on contractor personnel working onsite. It collects individual and company information for the investigation.

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Contractor Background Investigation Request

VA Organization Billing Information

Upload signed request to SIC Resource Site.

Printed/Distilled Copy

Only original can be submitted to SIC.

https://dvagov.sharepoint.com/sites/LIT/vasic/default.aspx

Organization: [ ]
Station:
Station Label: Station #
Date Label: Current Date:
Date:
Organization Label: VA Organization
City Of Birth Label: City of Birth
Date of Birth Label: Date of Birth
Company POC Label: Company POC
Company POC Email Label: POC Email Address
Company City Label: City
Company Zip Label: Zip
Last Name:
Middle Name:
Company State: [ ]
First Name:
Company State Label: State
Last Name Label: Last Name
Middle Name Label: Middle Name
First Name Label: First Name
SSN Label: SSN
SSN:
Gender:
Gender Label: Gender
Email Address:
Country of Citizenship: [ ]
Country Of Birth Label: Country of Birth
State of Birth Label: State of Birth
Email Address Label: Email Address
Country of Citizenship Label: Country of Citizenship
Position Title Label: Position Title
Company POC:
Position Title:
Priority Label: Priority
Child Care Label: Child Care
Priority: Off
Child Care: Off
Individual Information Label: Individual Information
Company Information Label: Company Information
COR Information: CO / COR
COR Name Label: Name of CO / COR
State of Birth: [ ]
Company Zip:
Company City:
Company POC Email: Use semicolons for multiple addresses.
COR Name:
Options Label: Additional options may be presented after an investigation is selected.
Investigation Label: Investigation
Investigation: [Select One...]
Contractor Company Label: Contractor Company
Contractor Company:
Task Order Number Label: Task Order Number
Task Order Number:
POC Address Label: POC Address
POC Address:
Phone Number Label: Phone Number
Phone Number:
Reinvestigation Label: Reinvestigation
Reinvestigation: Off
Include SAC Label: Include SAC
Include SAC: Off
Country of Birth: [ ]
State Instructions: Leave blank if foreign born.
City of Birth:
Date of Birth:
COR Email Label: CO / COR Email
COR Email: Use semicolons for multiple addresses.
Location:
Location Label: Location
Signature Label: Signature
Notes: Additional Notes

File details come from the government source that posted it. Updated .