Form Gsa 850 - Temporary Contractor Information Worksheet - 2012
Download a blank fillable Form Gsa 850 - Temporary Contractor Information Worksheet - 2012 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Gsa 850 - Temporary Contractor Information Worksheet - 2012 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2TEMPORARY CONTRACTOR INFORMATION WORKSHEET
OMB Number: 3090-0283
(Temporary Contractors for American Recovery and Reinvestment Act of 2009 Efforts:
Expires: 12/31/2012
Working on Contract 6 Months or Less & Require Physical Access Only)
Instructions to Complete this Form
1. Follow the instructions given to you by the person from GSA who gave you the form and any other clarifying instructions furnished by that person to
assist you in completion of the form.
2. You must sign and date, in black or blue ink, the original and submit the original to GSA.
3. Type or legibly print your answers in black or blue ink (if your form is not legible, it will not be accepted).
4. All questions in Section A on this form must be answered. If no response is necessary or applicable, indicate this on the form (for example, enter
"None" or "N/A"). If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by
marking "APPROX." or "EST."
5. Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited circumstances, GSA may modify
the form consistent with your intent.
6. You must use U. S. Postal Service 2-letter state abbreviations when you fill out this form. Do not abbreviate the names of cities or foreign countries.
7. All telephone numbers must include area codes.
8. All dates provided on this form must be in Month/Day/Year (mm/dd/yy) or Month/Year (mm/yy) format. Use numbers (1-12) to indicate months. For
example, May 27, 1972, should be shown as 5/27/72.
9. If you need additional space to complete the form, please use a separate blank sheet of paper.
Section A: To Be Completed By Temporary Contractor
1. Name (Last/Family)
2. First (Given)
3. Middle
4. Other Names Used
5. Suffix
(or NMN if none)
6. Social Security Number
7. Date of Birth
8. Place of Birth (City and State)
9. Country
10. Gender
11. Home Street Address
12. E-Mail Address (Optional)
13. Daytime Phone Number
14. Cell Phone Number
15. City
16. State
17. Zip Code
18. Position (Job) Title
19. U.S. Citizen?
Non-US Citizens Only: Complete 20-23
20. U.S. Port of Entry City and State
21. Date of Entry
22. Alien Registration Number
23. Country of Citizenship
24. Comments (A separate blank sheet of paper can be included for comments if additional space is needed)
Section B: To Be Completed By GSA
1. Company Name
2. Company is Prime or Subcontractor?
3. If Subcontractor, Name of Prime
Prime
Subcontractor
4. Contract / Task Order / RWA Number
5. Contract Start Date
6. Contract End Date
7. Company Point of Contact (POC) Name
8. POC Daytime Phone Number
9. POC E-Mail Address
10. GSA Building Number
11. Building Name
12. Building Address
13. Contractor Type (PBS or
14. Has Prior FBI National Criminal History Check (NCHC) on a GSA Contract
15. Prior NCHC Check Date
Non-PBS)
in the Last 6 Months?
16. Requesting Official’s Name
17. Requesting Official’s Title
18. Is Requesting Official COR / COTR?
19. Requesting Official’s E-Mail Address
20. Requesting Official’s Daytime Phone Number
21. Requesting Official’s Office Symbol
22. GSA Region
PAGE 1 OF 2
GSA 850 (REV. 12/2009)
GENERAL SERVICES ADMINISTRATION
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial