S02 - Attachment 9 VSC Form 3 PIV Form_April 2012.docx

Department of Veterans Affairs VHA Service Center Personnel Security 6100 Oak Tree Blvd #500 Independence, OH 44131 VSCSecurity@va.gov

PIV SPONSORSHIP INSTRUCTIONAL FORM 3A

Purpose: The PIV Sponsorship Form is used to complete the PIV badge application through the nationwide portal. All information is required to process a PIV badge. All fields are mandatory except the VA.GOV email address.

Full Legal Name: Please provide full legal name of individual as shown on driver’s license or photo ID.

Date of Birth: Please provide the date of birth of the individual.

Social Security Number: Please provide the social security number of the individual.

Citizenship: Please provide the citizenship of the individual. All foreign-born individuals will be required to submit proof of citizenship.

Assigned Duty Station: Please provide the name of the individual’s assigned duty station.

Address of Assigned Duty Station: Please provide the complete address of the assigned duty station.

VA.GOV Email Address: Please provide the va.gov email address of the individual. If the individual has not had the email address established, or will not be obtaining an email address, please indicate pending or not applicable.

Gender: Please provide gender of individual. Race: Please provide race of individual. Height: Please provide height of individual. Weight: Please provide weight of individual.

Eye Color: Please provide eye color of individual. Hair Color: Please provide hair color of individual.

M Place of Birth: Please provide city, state and country of individual’s place of birth. All foreign-born individuals will be required to provide proof of citizenship.

Position Title: Please provide position title of individual.

Contractor Company Name: Please provide the contracting company that the individual will be working under. If the individual is a VA employee, please indicate not applicable.

Contracting Company Address: Please provide the contracting company address. If the individual is a VA employee, please indicate not applicable.

Department of Veterans Affairs VHA Service Center Personnel Security 6100 Oak Tree Blvd #500 Independence, OH 44131 VSCSecurity@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 * ® Full Legal Name (First Middle Last): ® Date of Birth (MM/DD/YYYY):

© Social Security Number:

® Citizenship:

(US Citizen, Naturalized, Non-Citizen)

® Assigned Duty Station:

® Address of Assigned Duty Station: © VA.GOV Email Address:

0 Gender:

® Race:

© Height:

@ Weight:

© Eye Color:

M Hair Color:

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

© Position Title:

® Contractor Company Name:

© Company Address:

Revised Form April 2012 image2.png image1.png