RFP Attachment (8)_Fingerprinting Form 2.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

CONTRACTOR/EMPLOYEE FINGERPRINTING REQUEST FORM #2

SON: 955C / SOI: VA08 IPAC/OPAC: 3600.1200

(Please see Instructional Form #2a for assistance in completing this form)

** This form must be taken to the fingerprinting appointment **

EMPLOYEE INFORMATION (PLEASE PRINT)

A Full Legal Name (First Middle Last):

B SSN Last Four:

C Contractor/Federal/Other:

WE DO NOT REQUIRE THIS FORM BACK UNLESS THE PRINTS ARE MANUAL.

FACILITY INFORMATION

Electronically / Manually **Manual Prints will delay your prescreening**

D VAMC Name & Location:

E PIV Office Official :

F Date Fingerprinted:

G Method of Fingerprinting:

H Date Card Mailed to VSC: