Department of Veterans Affairs
Special Agreement Check (SAC) Fingerprint Verification Form
<Month<Year>
Version <#.#>
This template contains a paragraph style called Instructional Text. Text using this paragraph style is designed to assist the reader in completing the document. Text in paragraphs added after this help text is automatically set to the appropriate body text level. For best results and to maintain formatting consistency, use the provided paragraphs styles.
Revision History
Date / Version / Description / Author /Place latest revisions at top of table.
Special Agreement Check (SAC) Fingerprint Verification Form
Part A – Contract Information
To be completed by the Contracting Officer Representative (COR)
Contract No.: Order No.: Award Date:
COR (Full Name): COR Phone:
COR Email: COR Fax:
Part B – Contractor Employee Information
To be completed by the Contractor Employee
Employee (Full Name):
Employee Social Security No.:
Contractor Company Name:
Part C – VA Security Use Only
To be completed by VA Security Specialist
Submitting Office No. (SON): Security Office Identifier (SOI):
Facility Name: Station No.:
Date Fingerprinted: Method: Electronically
Person Taking Fingerprint (Full Name):
Signature of VA Security Specialist/Fingerprint Technician
*After fingerprints are captured, the contractor shall scan, fax, or email (encrypted) this completed document to the COR identified in Part A above
** The ISO Locator List can be accessed at the following link: https://vaww.infoprotection.va.gov/ISO-PO-Locator/default.aspx
Template Revision History
Date / Version / Description / Author /March 2012 / 1.0 / Initial Version / Process Management
Place latest revisions at top of table.
Remove before publication of document.