SOW_Exhibit_7_b.pdf
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- HSHQEC-16-R-00001
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Exhibit 7b
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Employee's Name
Employee's SSN
Contractor's Name
Contract Number
Exhibit 7b Contractor's Validation of
Pre-employment Requirements
First/MI/Last
Last 4 only
New Hire Incumbent PSO
Contractor Employee Status
1. Exhibit 7a, Contractor's Validation of Employee Personal Data
2. HSPD-12 (PIV or PIV-I)
3. Photograph
4. Fitness Decision Letter (Final or Preliminary)
5. National Security Information Clearance Letter, when applicable
6. DHS 11000-6, Non-Disclosure Agreement (Exhibit 3)
7. Physician's Certification (signature page only) (Exhibit 12)
8. Drug Screening
9. Basic Training Certification (Exhibit 7)
10. FPS Orientation Certification (Exhibit 7)
11. AED/CPR/First Aid Certification (AHA/ARC) (Exhibit 7)
12. EMT Certification (NREMT), when applicable (Exhibit 7)
13. WDTP Certification or Screener (X-ray/Mag), when applicable (Exhibit 7)
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Qualified (Q) Unqualified (UQ)
Employee's Name Employee's SSN
First/MI/Last Last 4 only
14. Lautenberg Statement (Exhibit 5)
15. Firearms Training Certification (Exhibit 7)
16. Firearms Qualification Certification (Exhibit 7)
17. Baton Certification, when applicable (Exhibit 7)
18. OC Certification, when applicable (Exhibit 7)
19. State Guard License (Exhibit 7)
20. State Weapons Qualification (Exhibit 7)
21. State Weapons Permit (Exhibit 7)
22. State Driver's License (Exhibit 7)
23. Other, when applicable (Exhibit 7)
24. Other, when applicable (Exhibit 7)
25. Other, when applicable (Exhibit 7)
Date
Date
Date
Define
Define
Define
Date
Date
Date
Date
Date
Date
Information provided in this certification is subject to investigation and verification under Title 18, Section 1001, United States Code.
Any false or misleading information may be punishable by fine and/or imprisonment.
Signature DateFPS Representative's Signature (Required)
FPS Representative
Title/First Initial/Last
I hereby certify the above named contractor employee has successfully met all pre-employment requirements and all documentation has been validated.
Signature DateAuthorized Contractor Representative Signature (Required)
Authorized Contractor Representative
Title/First Initial/Last
I hereby certify the above named contractor employee has successfully met all pre-employment requirements and has completed all initial training and certification requirements in accordance with the Statement of Work.
The contractor employee is prepared to take the PSO Basic Training Examination. (Maintain this exhibit and associated documents (copy or original) in the electronic PSO Personnel File.)
Last 4 onlyFirst/MI/Last
Employee's SSNEmployee's Name
Comments
Comments
Exhibit 7b Contractor's Validation of Pre-employment Requirements First/MI/Last Last 4 only Contractor Employee Status
1. Exhibit 7a, Contractor's Validation of Employee Personal Data
2. HSPD-12 (PIV or PIV-I)
3. Photograph
4. Fitness Decision Letter (Final or Preliminary)
5. National Security Information Clearance Letter, when applicable
6. DHS 11000-6, Non-Disclosure Agreement (Exhibit 3)
7. Physician's Certification (signature page only) (Exhibit 12)
8. Drug Screening
9. Basic Training Certification (Exhibit 7)
10. FPS Orientation Certification (Exhibit 7)
11. AED/CPR/First Aid Certification (AHA/ARC) (Exhibit 7)
12. EMT Certification (NREMT), when applicable (Exhibit 7)
13. WDTP Certification or Screener (X-ray/Mag), when applicable (Exhibit 7)
First/MI/Last Last 4 only
14. Lautenberg Statement (Exhibit 5)
15. Firearms Training Certification (Exhibit 7)
16. Firearms Qualification Certification (Exhibit 7)
17. Baton Certification, when applicable (Exhibit 7)
18. OC Certification, when applicable (Exhibit 7)
19. State Guard License (Exhibit 7)
20. State Weapons Qualification (Exhibit 7)
21. State Weapons Permit (Exhibit 7)
22. State Driver's License (Exhibit 7)
23. Other, when applicable (Exhibit 7)
24. Other, when applicable (Exhibit 7)
25. Other, when applicable (Exhibit 7) Information provided in this certification is subject to investigation and verification under Title 18, Section 1001, United States Code. Any false or misleading information may be punishable by fine and/or imprisonment.
FPS Representative's Signature (Required) Title/First Initial/Last I hereby certify the above named contractor employee has successfully met all pre-employment requirements and all documentation has been validated.
Authorized Contractor Representative Signature (Required) Title/First Initial/Last I hereby certify the above named contractor employee has successfully met all pre-employment requirements and has completed all initial training and certification requirements in accordance with the Statement of Work.
The contractor employee is prepared to take the PSO Basic Training Examination. (Maintain this exhibit and associated documents (copy or original) in the electronic PSO Personnel File.)
Last 4 only First/MI/Last 8.2.1.4029.1.523496.503679
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