Fingerprint Record Prep Sheet BLANK.PDF
PDF 105 KB Posted
- Solicitation number
- 36C25821B0004
About this file
This solicitation requests proposals for replacing a linear accelerator at the Greater Los Angeles Veterans Affairs Health Care System campus in West Los Angeles. The contractor shall demolish the existing linear accelerator, assist with installing a new linear accelerator and Accuray Radixact system provided by the equipment vendor. Additional work includes renovating rooms for the linear accelerator, control room, mechanical room, and data server room. The contractor must also replace ceiling, flooring, wiring, lead shielding, air systems, ductwork, drywall, finishes, casework and paint. Structural bracing, foundations and supports must meet seismic requirements. Electrical work includes power for the lift, linear accelerator and associated equipment, along with new controls and security systems. The contractor must coordinate all work with the equipment vendor and ensure all existing equipment is removed.
View the file
Other files
Show all 15
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
FINGERPRINT RECORD
PREP SHEET
Circle one: YOUR Employment Status below Applicant Current Employee Volunteer Contractor Renewal (PIV) Student WOC Resident Fellow Fee Basis Background (INV)
____ COURTESY SON: _______ SOI: __________
____ Unclassifiable (HR Staff ONLY) ________________________
FULL NAME
(LAST, FIRST MIDDLE)
FULL Social Security Number (SS#)
DOB -
Month/Date/Year
ALIAS (other names used) If none, write NONE
SEX
RACE – (if applicable, specify ETHNICITY)
EYE COLOR
HAIR COLOR
HEIGHT
(FT/IN)
WEIGHT
(LBS)
PLACE OF BIRTH
(STATE / COUNTRY)
COUNTRY OF
CITIZENSHIP
SERVICE OR DEPT.
(within the VA)
POSITION - Title (within the VA)
PHONE NUMBER
(where we can reach you)
E-MAIL ADDRESS
(VA or personal)
HOME ADDRESS
Signature of Person being Fingerprinted:_______________________________________________ Please have ready 1 (one) form of current photo ID HR Staff ONLY
DATE PRINTED: __________ PRINTED/COMPLETED BY:________________________
Revised 4/23/2015 (HR Security Staff ONLY)
PLEASE PRINT CLEARLY
Assignment over 180 days (circle one)
Yes No
Providing Direct Patient Services (circle one)
Yes No
CITY
STREET
STATE ZIP CODE
File details come from the government source that posted it. Updated .