S02 D.2.4 WMC Self Certification Form.pdf
PDF 322 KB Posted
- Solicitation number
- 36C25725Q0468
About this file
The document is a Self Certification of Continuous Service form from the Department of Veterans Affairs' WMC-HROO Personnel Security Contractor Processing Team. The form requires individuals to certify their break in service status from federal employment, which is defined broadly to include military service (Active, Guard, or Reserve), federal civilian employment, or work as a federal contractor/subcontractor. The form provides four checkbox options for documenting service breaks: no break, break less than 60 days, break between 60 days and two years (which requires submitting an OF 306 form), or break greater than two years or no previous federal employment. The form includes fields for personal information, signature, and a section for VHA Personnel Security/HR use to record investigation and risk level details.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25725Q0468 0004.docx | DOCX document | |
| S02 D.3 Fillable Schedule of Services 10.7.2025 02.xlsx | XLSX spreadsheet | |
| S02 D.3 Fillable Schedule of Services 10.7.2025.xlsx | XLSX spreadsheet | |
| 36C25725Q0468 0003.docx | DOCX document | |
| 36C25725Q0468 0002.docx | DOCX document | |
| 36C25725Q0468 0001.docx | DOCX document | |
| S02 D.2.1 WMC Contractor Request.pdf | ||
| S02 D.6 Contractor Certification - Immigration and Nationality Act.docx | DOCX document | |
| S02 D.3 Fillable Schedule of Services.xlsx | XLSX spreadsheet | |
| S02 D.2.3 Declaration for Federal Employment.pdf | ||
| S02 D.2.2 WMC Fingerprinting Request Form.pdf | ||
| S02 D.7 Organizational Conflict of Interest.docx | DOCX document | |
| S02 D.5 Contractor Rules of Behavior.docx | DOCX document | |
| S02 D.4 Experience Worksheet - Technical Capabilities.docx | DOCX document | |
| 36C25725Q0468_1.docx | DOCX document | |
| S02 D.1 Quality Assurance Surveillance Plan.docx | DOCX document |
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Text version
Department of Veterans Affairs WMC-HROO Personnel Security Contractor Processing Team
Self Certification of Continuous Service
I have NOT had a break in service.
My break in service was less than 60 days.
My break in service was greater than 60 days, but less than two (2) years. (You are required to submit the OF 306, Declaration for Federal
Employment, with this form.)
My break in service is greater than two (2) years; or I have never had federal employment as defined above.
Print Name: Social Security Number:
Signature: Date:
VHA Personnel Security/HR Use Only:
Current Investigation in PIPS: Date:
Risk level of current position: Verified by:
(Check One)
Federal employment is defined as any branch of the United States military (Active, Guard or Reserve), federal government civilian employee
(any federal government agency), or a contractor or sub-contractor working for the federal government.
Self Certification of Continuous Service Form Revised June 16, 2022
Previous Versions are Obsolete
I hereby certify my break in service from my last federal employment is indicated by the block checked above.
| I have NOT had a break in service: Off |
| My break in service was less than 60 days: Off |
| My break in service was greater than 60 days but less than 2: Off |
| My break in service is greater than 2 years or I have never worked: Off |
| Print Name: |
| Social Security Number: |
| Date: |
| Current Investigation in PIPS: |
| Date_2: |
| Risk level of current position: |
| Verified by: |
| Check Box1: Off |
| Check Box2: Off |
| Check Box3: Off |
| Check Box4: Off |
File details come from the government source that posted it. Updated .