U.s. Dol Vets Form 1010 - Omb No. 1293-0002
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4OMB NO. 1293-0002 (EXP 12/31/2016)
VETS/USERRA/VP Form 1010 (REV 12/2013)
ELIGIBILITY DATA FORM: For claims under the Uniformed Services Employment and Reemployment Rights Act (USERRA)
and/or claims under the Veterans’ Preference (VP) provisions of the Veterans Employment Opportunities Act of 1998
U.S. Department of Labor, Veterans’ Employment and Training Service
Mail (or FAX) to:
Veterans' Employment and Training Service
Phone: (866) 4-USA-DOL ((866)-487-2365))
U.S. Department of Labor
FAX:
(404) 562-2313
ATTENTION: Form 1010
61 Forsyth Street, S.W., Room 6T85
Atlanta, Georgia 30303
PLEASE TYPE OR PRINT
Section I: Claimant Information
Name:
1.
Last Name
First Name
M.I.
2. Address:
Street
City
State
ZIP
3
4
5
. Social Security No:
. Home Phone:
. Cell Phone:
6. Email Address:
7. Do you have a military service-connected disability?
Yes
No
Section II: Uniformed Service Information
8. Serve(d) In:
Air National Guard
Army National Guard
Army Reserve
Air Force Reserve
Naval Reserve
Marine Corps Reserve
Coast Guard Reserve
Army
Air Force
Navy
Marine Corps
Coast Guard
Public Health Service
Other (Explain in “Comments”)
None (Retaliation Claim – Explain in “Comments”)
9. If Reserve/National Guard:
(a)
Name of Unit:
(b)
Unit Address:
(c)
Unit Phone:
10. Dates of Service (If applicable):
(a) From:
To:
OR
(b) Date of Examination/Rejection for Service:
11. Type of Discharge or Separation:
Honorable Conditions
Entry Level
Uncharacterized
Medical
Other than Honorable
Other (Explain in “Comments”)
Not Applicable
Section III: Employer Information
12. Employer or Prospective Employer’s Name:
13. Address:
Street
City
State
ZIP
14. Principal Employer Contact (PEC):
(a) PEC Name/Title:
(b) PEC Phone:
15. Employment Dates (If applicable):
From:
To:
16. Since beginning work with this employer, has your cumulative uniformed service exceeded 5 years?
Yes
No
If YES, explain in Comments box at end of this claim form.
17. Name of Union(s) That Represent You:
18. Title of the Position or Occupation that is related to your claim (the job that you either now hold, or used to hold, or applied for, with this employer):
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