Self Certification of Continuous Service V2025 02.pdf
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- Solicitation number
- 36C25926R0003
About this file
This document is a Self Certification of Continuous Service Form from the Department of Veterans Affairs (VA) Personnel Security Adjudication Center. The form requires individuals to certify their break in service from federal employment, which is defined broadly to include military service (Active, Guard, or Reserve), federal civilian positions across any agency, or federal contractor roles. The form provides four checkbox options for reporting service breaks: no break, breaks less than 36 months, breaks between 36-60 months, or breaks greater than 60 months or no previous federal employment. Individuals must complete fields for their full name, Social Security number, signature, and date. The form was revised on February 12, 2025, with previous versions marked as obsolete.
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DEPARTMENT OF VETERANS AFFAIRS
OPERATIONS, SECURITY, AND PREPAREDNESS
PERSONNEL VETTING AND CREDENTIAL MANAGEMENT
PERSONNEL SECURITY ADJUDICATION CENTER
Self Certification of Continuous Service
I hereby certify my break in service from my last federal employment is indicated by the block checked below.
I have NOT had a break in service.
My break in service is less than 36 months.
[Date I left federal employment was _____________.]
My break in service is greater than 36 months, but less than 60 months. [Date I left federal employment was _____________.]
My break in service is greater than 60 months; or I have never had federal employment as defined above.
Full Name: Social Security Number:
Signature: Date:
(Select 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 working for the federal government.
Self Certification of Continuous Service Form Revised February 12, 2025
Previous Versions are Obsolete
| I have NOT had a break in service: Off |
| Print Name: |
| Social Security Number: |
| My break in service was less than 36 months: Off |
| My break in service is greater than 36 months, but less than 60 months: Off |
| My break in service is greater than 60 months or I have never worked: Off |
| Date of Form Completion_af_date: |
| Date Left Federal Employment 1_af_date: |
| Date Left Federal Employment 2_af_date: |
File details come from the government source that posted it. Updated .