SOW Attachment 03 - PIV Request Form.pdf
PDF 293 KB Posted
- Attached to
- C1DA--402-23-101, Demolish B222, 33, 34
- Solicitation number
- 36C24123R0147
About this file
This document is a Personal Identity Verification (PIV) request form for the Department of Veterans Affairs VA Maine Healthcare System Police Department. The form collects applicant information such as name, physical address, social security number, date of birth, place of birth, occupation, and service line or company affiliation for the purpose of conducting background checks and determining eligibility for a PIV or non-PIV badge. Engineers must also provide the contract end date. The form specifies the background check processes to be conducted by VA police records and local records and includes fields to document approval status and advancement through human resources.
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Text version
Project Name: Type of Badge Requested: PIV NON-PIV FLASH
Circle one
Departmentof Veterans Affairs
VA Maine Healthcare System
Police Department
1 VA Center 07B
Augusta, ME 04330
207 623-5796
Last Name First Name Middle
Physical Street Address City State and Zip Code
Social Security Number
Gender (M) (F)
Service Line or Company Name Company or Cell Phone Number
Date of Birth
Place of Birth Occupation Title
Personal email for activation of badge process
For Engineers to fill out:
Contract end date:
Service Line Official Date
All highlighted info must be submitted, or a badge cannot be issued
FOR TOG US POLICE USE ONLY
VISTA RECORDS:
DATE CHECKED BY RECORDS FOUND TYPE
VAPS RECORDS:
DATE CHECKED BY RECORDS FOUND TYPE
LOCAL RECORDS:
DATE CHECKED BY RECORDS FOUND TYPE
STATUS F YES NO ADVANCED TO HR
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File details come from the government source that posted it. Updated .