S02 - Att4 - Contractor Badging - Fingerprint Request Form.pdf

Applicant Category: Check One

EMPLOYEE CONTRACTOR

HEALTH PROFESSONS TRAINEE

(VHA intern, resident, fellow, student)

AFFILIATE VOLUNTEER OTHER:

ENTER YOUR NAME EXACTLY AS IT APPEARS ON IDs

Name: (Last, First, Middle) Other Last Names Used

SSN (use of pseudo number is not permitted) Position Title Telephone #

Date of Birth: (mm/dd/yyyy) City/State and Country of Birth

E-Mail Address Country of Citizenship Dual Citizen?

VA Work Location Organization (VHA, VBA, NCA, VACO, etc.

Contractors Only: Company Name Company Address/Work Email

Health Professions Trainees Only: School Name Training Program

FINGERPRINT LOCATION FINGERPRINT DATE (mm/dd/yyyy) PREVIOUS VA PIV CARD HOLDER (Yes/No)

GENDER (M/F) HEIGHT (inches) WEIGHT (US pounds) HAIR COLOR EYE COLOR RACE/ETHNICITY

FINGERPRINT REQUEST FORM

Bring with you two (2) original IDs (Identity Source Documents) from the list below https://www.oit.va.gov/programs/piv/_media/docs/IDMatrix.pdf

Complete all fields on this form to the best of your ability

Start Date

Courtesy Prints for another Facility:

Facility: _______________________________________

SOI# _______________

SON# ______________

Fingerprint Results Cleared: YES NO (Circle One) Date/Initials of Clearance: ___________________________________ https://www.oit.va.gov/programs/piv/_media/docs/IDMatrix.pdf VHAHINTumpiJ Text Box Any previous ID badge

VHAHINTziavT Text Box

VAS0

VHAHINTziavT Text Box 430H

VHAHINTziavT Text Box

Identifying documents NOT

ACCEPTED by USAccess include, but are not limited to:

1. Student ID Cards (including public/state universities, as well as private universities)

2. Gun or Firearms permits

3. License to Carry

4. Hunting/Fishing permits

5. Facility Badge

6. Temporary driver’s licenses

7. Selective service card

8. Company ID Card

9. Foreign Driver’s License (other than Canada)

10. Library Card

11. Temporary PIV Card

12. Marriage license

Primary Forms of Identification (Acceptable

Documents)

1. U.S. Passport or a U.S. Passport Card

2. Permanent Resident Card or an Alien Registration Receipt Card (Form I-

551)

3. Foreign passport

4. Employment Authorization Document that contains a photograph (Form I-

766)

5. Driver's license or an ID card issued by a state or possession of the United

States provided it contains a photograph

6. U.S. Military ID card

7. U.S. Military dependent's ID card; or

8. PIV Card.

Issue No. 20-

USAccess Deployment Bulletin

USAccess Identity Proofing Source Documents

Week of December 28, 2020

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Identifying Source

Documents Not Accepted for USAccess is Coming… Are You Ready?

Issue No. 20-45

USAccess Enrollment and Identity Proofing Documents

Secondary Forms of Identification (Acceptable

Documents)

1. U.S. Social Security Card issued by the Social Security Administration.

Laminated SSA cards cannot be used without Security Officer approval.

2. Original or certified copy of a birth certificate issued by a state, county, municipal authority, possession, or outlying possession of the United

States bearing an official seal

3. ID card issued by a federal, state, or local government agency or entity, provided it contains a photograph. EXCEPTIONS APPLY

4. Voter's registration card; 13. Reentry Permit (Form I-327)

5. U.S. Coast Guard Merchant Mariner Card

6. Certificate of U.S. Citizenship (Form N-560 or N-561)

7. Certificate of Naturalization (Form N-550 or N-570)

8. U.S. Citizen ID Card (Form I-197)

9. Identification Card for Use of Resident Citizen in the United States (Form I-

179)

10. Certification of Birth Abroad or Certification of Report of Birth issued by the

Department of State (Form FS545 or Form DS-1350)

11. Temporary Resident Card (Form I-688)

12. Employment Authorization Card (Form I-688A)

13. Reentry Permit (Form I-327)

14. Refugee Travel Document (Form I-571)

15. Employment authorization document issued by Department of Homeland

Security (DHS)

16. Employment Authorization Document issued by DHS with photograph

(Form I-688B)

17. Driver's license issued by a Canadian government entity

18. Native American tribal document.

The following rules apply to all presented identity source documents:

• All documents must be in their original forms - no photocopies other than a certified copy of birth certificate bearing an official seal.

• Expired or canceled identity documents are not a cceptable.

• All Primary forms of ID contain an expiration date;

however, some Secondary forms of ID do not. Not having an expiration date does not make a

Secondary ID Source unacceptable. Secondary forms of ID without an expiration date can be accepted.

• Up dating or replacing identity source documents is n o t required after successfully completing the id entity proofing process.

• If any of the identity source documents presented for identity proofing bear different names, then evidence of a formal name change must be provided linking the names. For example, a married woman with a current driver’s license and birth certificate can provide a marriage license.

Photos are required for all forms of primary identification documents.

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