Veteran Preference Form (Page 2 of 2) in pdf

QUALIFIED DISABLED VETERAN QUESTIONS: You may claim additional preference as a

disabled veteran if you check at least one box below and provide proof of eligibility by submitting

a copy of your DD- 214 or 215 (long form/Member Copy-4) that reflects your honorable

separation status and a public employment preference letter from the Department of Veterans’

Affairs, unless the information is already included in the federal DD Form 214/215

ORS 408.225 (1)(c)

I am entitled to disability compensation under laws administered by the United

States Department of Veterans Affairs; or

I was discharged or released from active duty for a disability incurred or

aggravated in the line of active duty; or

I was awarded the Purple Heart for wounds received in combat.

I receive a non-service connected pension from the United States Department of

Veterans Affairs.

Under Oregon law:

5 (five) points may be awarded to eligible veterans.

10 (ten) points may be awarded to eligible disabled veterans.

After reviewing the veteran preference information on the first page, do you claim

veteran points?

Yes

If claiming veteran preference points, how many do you claim?

5 (five) veteran preference points

10 (ten) veteran preference points

Note: Once you submit this form and the information contained therein is verified, you

will not be required to resubmit this documentation to HACSA. Should your personal

circumstances change and you claim additional points (i.e. should you qualify for points

as a disabled veteran), you will be required to notify HACSA and resubmit this form and

additional documentation as necessary.

Preference will not be applied unless you submit the appropriate documentation by two

business days after the closing date.

I hereby claim veteran preference points and certify that the above information is

true and correct. I understand that any false statements may be cause for my

disqualification or dismissal, regardless of when discovered.

_______________________________

Applicant’s Name

_______________________________

Applicant’s Signature

Date

Veteran Preference Form Page 2