SOW Attachment - Security Badge form.pdf

This is a badge request form for the VA Maine Healthcare System Police Department, located at 1 VA Center 07B, Augusta, ME 04330. The form is used to request one of three types of badges: PIV (Personal Identity Verification), NON-PIV, or FLASH. The form must be completed in full for badge issuance, with all highlighted information fields being mandatory.

The applicant information section requires submission of personal details including last name, first name, middle initial, physical street address, city, state, zip code, Social Security number, gender, date of birth, place of birth, occupation title, service line or company name, and company or cell phone number. Additionally, applicants must provide a personal email address for badge activation. For contract engineers, the form requires the contract end date and the service line official's name and date. The second page contains a restricted section for TOGUS Police use only, which includes checkboxes for records verification across three database systems: VISTA Records, VAPS Records, and Local Records. For each system, the form tracks the date checked, checking officer, records found status, and record type. A final status section indicates whether the application was approved or denied and whether it was advanced to Human Resources.