Get Lebanon Medical Attachment Form

ATTACHMENT TO SF-85 The attached affidavit must be completed before we can appoint you. This form along with a copy of your fingerprints which will be made at the VA Medical Center by the Police Service are necessary for your security investigation. If this form is not completely filled out it WILL be returned until ALL questions are answered. Complete as much as possible prior to your appointment date. If you have any questions contact HUMAN RESOURCES 121 VA MEDICAL CENTER 1700 S. LINCOLN AVENUE LEBANON PA 17042 717 272-6621 extension 4053 or 4054 If you intend to drive your own vehicle to work you must also bring your driver s license vehicle registration for each vehicle you may drive to work and insurance verification. FULL NAME - NO INITIALS LAST NAME FIRST NAME MIDDLE NAME RESIDENCE OF PERSON FINGERPRINTED COMPLETE ADDRESS DATE OF BIRTH MONTH/DAY/YEAR SEX RACE HEIGHT PLACE OF BIRTH CITY STATE EYE COLOR HAIR COLOR SCARS MARKS AND TATTOOS POSITION TO WHICH APPOINTED SOCIAL SECURITY NUMBER ALIASES Maiden Name or other Married Names U.S. Citizen Yes No. ATTACHMENT TO SF-85 The attached affidavit must be completed before we can appoint you. This form along with a copy of your fingerprints which will be made at the VA Medical Center by the Police Service are necessary for your security investigation* If this form is not completely filled out it WILL be returned until ALL questions are answered* Complete as much as possible prior to your appointment date. If you have any questions contact HUMAN RESOURCES 121 VA MEDICAL CENTER 1700 S* LINCOLN AVENUE LEBANON PA 17042 717 272-6621 extension 4053 or 4054 If you intend to drive your own vehicle to work you must also bring your driver s license vehicle registration for each vehicle you may drive to work and insurance verification* FULL NAME - NO INITIALS LAST NAME FIRST NAME MIDDLE NAME RESIDENCE OF PERSON FINGERPRINTED COMPLETE ADDRESS DATE OF BIRTH MONTH/DAY/YEAR SEX RACE HEIGHT PLACE OF BIRTH CITY STATE EYE COLOR HAIR COLOR SCARS MARKS AND TATTOOS POSITION TO WHICH APPOINTED SOCIAL SECURITY NUMBER ALIASES Maiden Name or other Married Names U*S* Citizen Yes No.