RFP Attachment (10)_PIV Sponsorship.pdf

Revised Form November 2018

Department of Veterans Affairs VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

VHA SERVICE CENTER PIV SPONSORSHIP FORM #3

(Please see Instruction Form #3a for assistance in completing this form)

CONTRACTOR / EMPLOYEE INFORMATION

* All fields are mandatory except va.gov email *

(US Citizen, Naturalized, Non-Citizen)

A Full Legal Name (First Middle Last):

B Date of Birth (MM/DD/YYYY):

C Social Security Number:

D Citizenship:

E Assigned Duty Station:

F Address of Assigned Duty Station:

G VA.GOV Email Address:

H Gender:

I Race:

J Height:

K Weight:

L Eye Color:

M Hair Color:

N Place of Birth (City, State, Country):

O Position Title:

P Contractor Company Name:

Q Company Address:

Street Address, City, State, Zip Code