Current Employee Pre-Employment Contractor Locum-Volunteer Student Work Study

Current Employee--Pre-Employment–Contractor–Locum-Volunteer– Student--Work Study

F I N G E R P R I N T P R E P S H E E T SON: 1385 SOI: VAE0 (zero) FULL NAME (Last, First Middle):

FULL SSN (xxx-xx-xxxx): ALIAS / MAIDEN NAME(S): DATE OF BIRTH (yyyy/mm/dd): Are you a current or former volunteer at the VA? Yes No Do you use a laptop for your position at the VA? Yes No If “Yes,” for how long: ______Years & ______Months COUNTRY OF CITIZENSHIP: PLACE OF BIRTH (City, State): CURRENT POSITION OR POSITION APPLIED FOR:

GENDER (select one): Male Female

Asian Black or African American ETHNICITY (select one): Native American Caucasian

Other (specify): ______Latino EYE HAIR HEIGHT WEIGHT COLO (feet/inch COLOR: (lbs): R: es):

Cell PHONE (specify):

Home EMAIL ADDRESS:

This Section for Human Resources Use ONLY Date Fingerprinted: Fingerprinted By:

For Pre-Employment? Y N For PIV Badge? Y N Sponsored Y N

Photo Taken? Y N Index Prints Taken? Y N