PIV Office Fingerprint Request Form.pdf

Revised Form October2016

CONTRACTOR / EMPLOYEE PIV Office FINGERPRINT Request FORM

Security and Investigations Center

SON: 430H / SOI: VAS0

CONTRACTOR / EMPLOYEE INFORMATION (PLEASE PRINT)

A Full Legal Name (First Middle Last):

B SSN Last Four:

C Contractor Company (If Applicable):

PIV Badge Office INFORMATION

D PIV Badge Office Location:

E Contact Number (If Applicable):

F Date Fingerprinted:

G Method of Fingerprinting:

Electronically / Manually

Purpose of Form:

This PIV Office Fingerprint Form was created to assist Human Resources (HR) / Contracting Officer Representatives (CORs) with providing their contractors / employees the SIC's SON / SOI in obtaining fingerprinting services from VA Facilities nationwide.

Special Notes:

1. If fingerprints are manually taken, please ensure the FD-258 Fingerprint Card is used and mailed directly to the SIC at the following address:

Security and Investigations Center 2200 Fort Roots Dr Bldg 192 North Little Rock, AR 72114.

2. The SIC is not involved with PIV appointments or issuance of PIV cards. Contractors / Employees should be instructed to contact their local PIV Badge Office for PIV appointments.

3. This form is NOT required to be uploaded to the SIC's Resource Site.

4. HR / CORs are required to submit a SAC Request Form to the SIC's Resource Site if SIC's SON / SOI is used.

** If using the Security and Investigations Center (SIC) to adjudicate your VA Contractor or Employee's Special Agreement Check (SAC) Fingerprints, this form should be taken to the fingerprinting appointment to ensure correct SON / SOI is used**

Please contact the SIC Help Desk at 501-257-4469 or 257-4490 or by email at vhalitbackgroundinvestigations@va.gov if you have questions on the background investigation process.