Personal Identification Verification (Piv) Card Form

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Personal Identification Verification (PIV) Card Form
____FIRST TIME ISSUE
____RENEWAL(expired or within 6 weeks of expiration)
____RE-ISSUANCE(lost card, card not working or taken by prior VA when transferred)
____NAME CHANGE(approved through HR & changed in VISTA/PAID)
“SPONSOR USE ONLY CHOOSE TYPE OF ID”:
____PIV
____NON-PIV
____FLASH BADGE
FIRST NAME:______________________________________________
FULL MIDDLE NAME:_______________________________________
LAST NAME: ______________________________________________
*BRING THIS COMPLETED FORM & TWO TYPES OF ID THAT MATCH YOUR NAME ABOVE TO THE SERVICE SPONSOR.
ONCE THE SPONSOR HAS UPLOADED YOU INTO THE PORTAL WAIT 72 HRS TO CALL THE PIV OFFICE FOR AN
APPOINTMENT. BRING TWO IDs MATCHING THE NAME ABOVE TO THE PIV OFFICE WHEN YOU GO FOR YOU
APPOINTMENT FOR PROCESSING. The two forms of ID can be your current VA ID and driver’s license, Passport, Military
ID, Voters Registration Card, SSAN Card, State Firearms Card, Certified Birth Certificate. One MUST be a photo ID.
DOB: ___________________________________________
SSN:___________________________________________
Service:__________________________________________
Mail Code:________________________________________
Job Title (Exactly as it appears in VISTA):_______________________________________________________
Appropriation Code or Cost Center (last 4 digits only)_____________________________________________
Height (Feet & Inches):________________________
Weight:_____________________________________
Eye Color (Spell out):__________________________
Hair Color (Spell out):__________________________
Gender:______________________________________
Race:
___American Indian or Alaskan Native ___Asian or Pacific Islander
___Black-Non Hispanic___Hispanic ___ White-Non Hispanic
Place of Birth
):__________________________________________
(City & State or Country Name if born outside the US
Work Phone:
VA Outlook Email Addrress:___________________________________________________________________
Emergency Responder: ____YES___NO
(Emergency Responders positions are found in the Services’ RED BOOK ONLY)
Critical Employee:
____YES____NO
(All medical professions should be Critical Employees)
CITIZENSHIP:
_____U.S. CITIZEN BY BIRTH
_____NATURALIZED U.S. CITIZEN
_____NOT A U.S. CITIZEN/COUNTRY OF CITIZENSHIP: _________________________________
IAW VA Directive 0735, failure to provide all of the requested information may result in VA being unable to process your request for a One-VA ID Card,
or denial of issuance of a One-VA ID Card. If you do not have a One-VA ID Card, you may not be granted access to VA facilities or networks, which
could have an adverse impact on your application to become, or status as, a VA employee, contractor or affiliate where such access is required to
perform your assigned duties or responsibilities.

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