· web viewva rep: robert lawsresponsible va org: nwihcs finger prints required: _x_ yes ___n o...
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Personal Identity Verification (PIV) Card Request Form
First Name: _____________ Middle Name: ______________ Last Name: ________________Generation Qualifier: ___ Jr/ ___ Sr/ ___II/ ___ III/___IV/___VNickname Used: ___________________________Date of Birth: _____/______/______ Full SSN: ______-____-________ Phone Number: _____________________________________E-Mail Address: ________________________________________________Is Applicant a Foreign National?: ___ No ___YesPosition Title: Nursing Student Employment Status: Affiliate – School NameVA Rep: Robert Laws Responsible VA Org: NWIHCSFinger Prints Required: _X_ Yes ___N oGender: ____ Female ____ MaleRace: ____ American Indian or Alaskan Native ____ Asian or Pacific Islander
____ Black non-Hispanic ____ Hispanic ____ White, Non-Hispanic
Height: ____Feet ____InchesWeight: ______lbsEye Color: ____ Black ____ Blue ____ Brown ____ Gray ____ Green
____ Hazel ____ Maroon ____ Multi-Colored ____ Pink ____ UnknownHair Color: ___________________Place of Birth (City, State, Zip Code, Country): __________________________________________
Send completed document to:Fax: (402) 995-3859 or (3437) Attn: Robert Laws (This is a secure location, so it is safe to send PII)E-Mail: [email protected] (please ensure you encrypt in outlook)Hand Deliver: Please contact Robert to arrange a time to meet (402) 995-5171
US Mail: NWIHCS, 4101 Woolworth Ave, Room 6417, Attn: Robert Laws, Omaha, NE 68105