Fillable Application For Veterans Preference Form printable pdf download

APPLICATION FOR VETERANS’ PREFERENCE

(TO BE USED BY VETERANS & RELATIVES OF VETERANS)

PERSON APPLYING FOR PREFERENCE

1. Name (Last, First, Middle)

2. Name of position within the Office of the Senate Sergeant at Arms for which you are applying

3. Home address (Street Number, City, State and ZIP Code)

4. Date application submitted

VETERAN INFORMATION (to be provided by person applying for preference)

5. Veteran’s name (Last, First, Middle) exactly as it appears on Service Records

6. VA claim number, if any

7. Veteran’s periods of service

Branch of Service

From

Service Number

TYPE OF VETERANS’ PREFERENCE CLAIMED

Instructions: Check the block which indicates the type of preference you are claiming. Answer all questions associated with that block. The Documentation Required column refers you to the

back of this form for the documents you must submit to support your application. (Please Note: Eligibility for veterans’ preference is governed by 5. U.S.C. § 2108 and applicable regulations. All

conditions are not fully described on this form because of space restrictions. You should submit this completed form to Human Resources, the Office of the Senate Sergeant at Arms.)

Documentation Required

(See reverse of this form)

8. Veteran’s Claim for Preference based on non-compensable, service-connected

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disability; award of the Purple Heart; or receipt of compensation, disability retirement

A and B



benefits or pension because of a public law administered by the VA or a military

department.

9. Veteran’s Claim for Preference based on (1) service during a war, campaign or

expedition for which a campaign badge has been authorized, (2) active duty service



during the period of April 28, 1952 through July 1, 1955, (3) service for more than 180

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consecutive days, any part of which occurred after January 31, 1955, and before

A and G

October 15, 1976 (excluding service under 10 U.S.C. 12103(d)), (4) active duty

service from August 2, 1990, through January 2, 1992, (5) active duty service for

more than 180 consecutive days, any part of which occurred during the period

beginning September 11, 2001, and ending on the date prescribed by Presidential

Proclamation or by law as the last day of Operation Iraqi Freedom.

Yes

10. Preference for a Spouse of a living veteran based on the fact that the veteran,

(a) Are you presently married to the

because of a service-connected disability, has been unable to qualify for a Federal or

veteran?

B and H



D.C. Government job or any other position along the lines of his/her usual

occupation. (If your answer to item 10(a) is No, you are ineligible for preference and

need not submit this form.)

11. Preference for a Widow or Widower of a Veteran.

(a) Were you married to the veteran

(If your answer is No to item 11(a) or Yes to item 11(b), you are ineligible for

when he or she died?

A, C, D, and F



preference and need not submit this form).

(Submit F when applicable.)

(b) Have you remarried since the



veteran’s death? Do not count

marriages that were annulled.

12. Preference for (Natural) Mother of a service-connected permanently and totally

disabled, or deceased veteran, provided you are or were married to the father of the

(a) Are you married?



veteran, and

Disabled Veteran

B, E, and H

--- your husband (either the veteran’s father or your husband of a remarriage) is totally

(b) Are you separated? If Yes, do not

(Submit E when applicable.)



and permanently disabled, or

complete (c), go to (d).

--- you are now widowed, divorced or separated from the veteran’s father and have not

remarried, or

Deceased Veteran



totally and permanently disabled?

A, C, D, and E

--- you are widowed or divorced from the veteran’s father and have remarried, but you

(Submit E when applicable.)

are now widowed, divorced or separated from the husband of your remarriage. (If

your answer is No to item 12(c) or 12(d), you are ineligible for preference and need

(d) If the veteran is dead, did he/she die



not submit this form.)

in active service?

The Veterans Employment Opportunity Act of 1998 (“VEOA”), as made applicable by the Congressional Accountability Act of 1995, as amended (“CAA”), authorizes the collection of this information.

Individuals who are entitled to a veterans’ preference are invited to self-identify voluntarily. The information and any accompanying documentation are intended solely for use in connection with the

obligations and efforts of the Office of the Senate Sergeant at Arms to provide veterans’ preference to preference-eligible applicants in accordance with the VEOA. An applicant’s status as a disabled

veteran and any information regarding an applicant’s disability, including his/her medical condition and history, that the Office of the Senate Sergeant at Arms obtains will be kept confidential and will

be collected, maintained and used in accordance with the Americans with Disabilities Act of 1990, as made applicable by section 102(a)(3) of the CAA, 2 U.S.C. § 1302(a)(3). An applicant who

declines to self-identify as a disabled veteran and/or provide information and documentation regarding his/her disabled veteran’s status will not be subjected to an adverse employment action but may

be ruled ineligible for a veterans’ preference. Applicants may obtain a copy of the Office of the Senate Sergeant at Arms’s Veterans’ Preference in Appointments policy by submitting a written request

resumes@saa.senate.gov

I certify that all of the statements made in this application are true, complete and correct to the best of my knowledge and belief and are made in good faith. (A false answer to any question may be

grounds for not employing you or for dismissing you after you begin work, and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001)).

This form must be signed by all persons claiming a veterans’ preference

Date signed

Signature of person claiming preference

(Month, Day, Year)

FOR USE BY HUMAN RESOURCES ONLY

Name and Title of person who verified veterans’ preference

Date of verification

(Month, Day, Year)



Preference entitlement was verified

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