SOW Attachment 05-PIV Badge Template - HVAC Resolicit.pdf
PDF 293 KB Posted
- Attached to
- Z1DZ--402-22-755 Replace Laundry HVAC
- Solicitation number
- 36C24124R0104
About this file
This document is a PIV (Personal Identity Verification) badge request form for the VA Maine Healthcare System Police Department. The template requires comprehensive personal information including name, address, Social Security number, gender, contact details, date and place of birth, occupation, and email. The form allows selection of badge type (PIV, NON-PIV, or FLASH) and includes a section specifically for engineers to note contract end dates. A second page is reserved for official police record checks, with spaces to document VISTA, VAPS, and local record verifications, along with a status and HR advancement notation. The form emphasizes that all highlighted information must be submitted to successfully process a badge, indicating strict documentation requirements for facility access.
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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 .