SOW Attachment - PIV Badge Template.pdf
PDF 293 KB Posted
- Solicitation number
- 36C24125Q0062
About this file
This is a Personal Identity Verification (PIV) badge request template form used by the VA Maine Healthcare System Police Department at the Togus VA Medical Center. The form captures essential personal information required for badge issuance, including the type of badge requested (PIV, NON-PIV, or FLASH), full name, physical address, social security number, gender, service line/company details, contact information, date of birth, place of birth, occupation title, and personal email for badge activation. For engineers, the form requires contract end date information. The template includes sections for police use only, covering VISTA records, VAPS records, and local records checks.
This template document appears to be related to the broader solicitation (36C24125Q0062) for underground vault closure and infill work at Togus VAMC, likely used for contractor personnel who will need facility access during the project execution.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24125Q0062 0002.docx | DOCX document | |
| 36C24125Q0062 0001.docx | DOCX document | |
| Site Walk Sign in Sheet.pdf | ||
| Wage_Determination_Heavy - ME20250022.pdf | ||
| SOW Attachment - Local Requirements.pdf | ||
| SOW Attachment - Specifications Package.pdf | ||
| SOW Attachment - Seasonal Influenza with Vaccines.pdf | ||
| SOW final 12-19-24.docx | DOCX document | |
| 36C24125Q0062_Solicitation.docx | DOCX document | |
| SOW Attachment - Structure Location Map.pdf | ||
| SOW Attachment - Togus Campus Map .pdf | ||
| 852.219-75 VA NOTICE OF LIMITATIONS ON SUBCONTRACTING.docx | DOCX document | |
| PCRA.pdf |
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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 .