SOW Attachment 05-PIV Badge Template - HVAC Resolicit.pdf
PDF 293 KB Posted
- Attached to
- Z1DZ--402-22-755 Replace Laundry HVAC
- Solicitation number
- 36C24124R0062
About this file
This document is a PIV Badge Request Form for the Department of Veterans Affairs (VA) Maine Healthcare System. The form requires the applicant to provide personal information such as name, address, social security number, and occupation title. The form is used to request a Personal Identity Verification (PIV) or non-PIV badge for access to the VA facility. All highlighted information must be submitted, or a badge cannot be issued. The form states that it is for VA Police use only and includes sections for checking VISTA, VAPS, and local records.
The related federal contract opportunity is a solicitation (Solicitation Number: 36C24124R0062) for the provision of labor, materials, and services to perform repair and replacement of the HVAC system located in the laundry rooms of the VAMC Maine, Togus Campus. The requirement is 100% set-aside for small businesses, and firms interested in submitting a proposal should do so in .PDF, .DOCX, or .DOC format via email to Andrew Baker at Andrew.baker@va.gov no later than June 6, 2024 at 5:00 PM EST. No compressed .ZIP files will be accepted.
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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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