W9127820Q0001_Solicitation_Attachment_1_PSIP_Form_v2.pdf

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Provide Park Attendant services at various recreational areas in the U. S. Army Corps of Engineers, Mobile District, Alabama, Mississippi, Georgia and Florida
Solicitation number
W9127820Q0001
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W9127820Q0001 Solicitation Attachment 1 PSIP Form version 2

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PSIP Requestor Guide Updated 9 June 2010

PSIP Required Information Worksheet Fill in all spaces

*SSN: ___________________________ *Birth Date: __________________ (MM/DD/YYYY)

*Rank/Prefix (Dr., Ms., Mrs., Mr.): ____ *Last Name: _____________________________

*First Name: ______________________ *Middle Name: _________ Initial Only/No Middle Name

*Postfix/Suffix (i.e.: II, III, Jr.): _______

*Country of Birth: __________________ *State of Birth: ______ *City of Birth: __________________

US Citizenship Proof: Birth Certificate / Certificate of Citizenship-INS/ Certificate of Naturalization / DS-1350 / FS-545 / Passport / FS-240 / Documentation Number:___________________________

Branch of Service: ARMY SOI: A343 IPAC Code: 00005570

Fingerprints Submitted: None / Electronic / Manual Date: ________________________________

Project:_________________________________

Park Attendant:__________ Volunteer: _________

PA Coordinator: _____________________________

Volunteer Coordinator:______________________

Subject Contact Information:

Email Address (AKO preferred): ____________________________________

Secondary Email Address: ________________________________________

Primary Phone: _________________Comm/DSN/Overseas

Secondary Phone: _______________Comm/DSN/Overseas

Organization /Unit Name: __________________ Organization/Unit UIC: W2SR04

Supervisor Contact Information: (Park Attendant COR or Volunteer Coordinator)

First Name: __________________________ Last Name: _____________________________

Title: _______________________________ Email: _________________________________

Phone: ________________________ Comm/DSN/Overseas k5optcag Typewritten Text k5optcag Typewritten Text k5optcag Typewritten Text Email to: theresa.l.mason@usace.army.mil OR kenneth.t.earls@usace.army.mil k5optcag Typewritten Text k5optcag Typewritten Text k5optcag Typewritten Text k5optcag Typewritten Text k5optcag Typewritten Text

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ATTACHMENT 1

PSIP FORM

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SSN:
RankPrefix Dr Ms Mrs Mr:
First Name:
PostfixSuffix ie II III Jr:
Country of Birth:
Birth Date:
Last Name:
Middle Name:
State of Birth:
City of Birth:
Documentation Number:
Reason for Access:
SOI:
Branch of Service:
Justification:
Text1:
Check Box1: Off
Check Box2: Off
Text4:
Text5:
Text6:
Text7:
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Text12:

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