Contractor Background Investigation Request Form REV

Current Date:

Contractor Background Investigation Request
(All Fields Are Mandatory - Please Complete Entire Form)

VA Organization Information
Servicing Personnel
Vetting Office (SPVO)

VA Assigned
Organization

HROO

O

Leave blank if foreign born.

State of Birth

SA
y oP
op t
C d
d tte
le mi
til
is ub
D s
d/ be
te
in an
Pr al c
in
ig

or

Middle Name

Country of Birth

Email Address

Country of Citizenship

Phone Number
Investigation

Date of Birth

City of Birth

y
nl

Individual Information

Last Name

Station #

Sex

SSN

First Name

VHA

Marital Status

Select One...

Select One...

Position Title

Contractor Company

Task Order Number

Use semicolons for multiple addresses.

Company POC

POC Address

POC Email Address

City

.

C

Company Information

Additional options may be presented after an investigation is selected. If Contractor is Not a U.S. Citizen, Completion of the Foreign National Check Form is Also Required.

State

Zip

Phone Number

CO / COR

Name of CO / COR
CO / COR Email

VA CO or COR

Signature Required

Additional Comments:

Upload signed request to PSAC Resource Site.
version February 4, 2025