VA119A-16-R-0349-A00002004.docx

ATTACHMENT D - VA CONTRACTOR BACKGROUND INVESTIGATION REQUEST WORKSHEET

The following applicant is a Contract employee.

Please complete the following fields on all applicants who have access to VA facilities, systems or privacy data:

Station where applicant will work:

Station Name – City: ____________________ State: _____ Station #: __________ Station to be billed for clearance:

Station Name – City: Washington State: DC Station #: 101 Please complete the following fields on each Contract Employee:

Applicant Name:

Last: ____________________ First: __________________ Middle: _______________

SSN: ________________ DOB: ________________ Email: _____________________ Place of Birth: City: ________________ State: _____ Country: _______ Contractor Occupation: ________________________________ Do you have a clearance pending or completed with OPM? Yes: No:

If yes, what level? _________ Are you asking for a low risk clearance on a foreign national? Yes: No:

Type of Investigation requested:

BI (High Risk): MBI (Moderate Risk): NACI (Low Risk):

Is this a security upgrade to the contract you are currently working? Yes: No:

VA COR: ___________________ VA COR Phone: ________________ VA COR Email: ____________________ Complete Address: 810 Vermont Avenue, NW City/State: Washington, DC Zip Code: 20420 Prime Contracting Company Name: __________________________________________ Prime Contracting Company POC: __________________________________________ POC Phone: _____________________ POC Email: ____________________________ Complete Address: _______________________________________________________ City/State: __________________________________ Zip Code: _________________

Contract Title: _____________________________________________ Call/Contract #: _______________________________________ Obligation #: _________________________________________

If you are a Sub, what is your Company Name? __________________________