Application For Accreditation As A Claims Agent Or Attorney (Page 2 of 4) in pdf

11A. ARE YOU CURRENTLY A MEMBER IN GOOD

11B. IF "YES," LIST EACH JURISDICTION IN WHICH ADMITTED, THE DATE OF ADMISSION, AND

STANDING OF THE BAR OF THE HIGHEST COURT

MEMBERSHIP OR REGISTRATION NUMBER.

OF A STATE OR TERRITORY OF THE UNITED STATES?

JURISDICTION IN WHICH ADMITTED

DATE OF ADMISSION

MEMBERSHIP OR REGISTRATION NO.

YES

12A. ARE YOU CURRENTLY ADMITTED TO PRACTICE

12B. IF "YES," LIST EACH AGENCY OR FEDERAL COURT TO WHICH ADMITTED, THE DATE OF

BEFORE ANY STATE OR FEDERAL AGENCY OR ANY

ADMISSION, AND MEMBERSHIP OR REGISTRATION NUMBER.

FEDERAL COURT?

AGENCY IN WHICH ADMITTED

DATE OF ADMISSION

MEMBERSHIP OR REGISTRATION NO.

YES

BACKGROUND INFORMATION: Truthfulness and candor are essential elements of good moral character and reputation relevant to practice before the Department

of Veterans Affairs. It is in your best interest; therefore, to provide the Office of the General Counsel with all available information in responding to the questions asked

below. For each question answered "YES," provide a detailed statement setting forth all relevant facts and dates along with copies of relevant documents.

Your responses must be updated as necessary prior to your accreditation. Failure to disclose the requested information may result in denial of accreditation under 38 C.F.

R. § 14.629 or in disciplinary proceedings under 38 C.F.R. § 14.633 if you are already accredited.

For questions 13 through 15 your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less,

(2) any violation of law committed before your 16th birthday, and (3) any conviction for which the record was expunged under Federal or state law.

13A. HAVE YOU EVER BEEN CONVICTED,

13B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURRENCE, AND THE NAME

IMPRISONED, SENTENCED TO

AND ADDRESS OF THE MILITARY AUTHORITY OR COURT INVOLVED.

PROBATION OR PAROLE? (Include felonies,

firearms or explosives violations, misdemeanors,

and all other offenses.)

YES

14A. HAVE YOU EVER BEEN CONVICTED,

14B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURRENCE, AND THE NAME

BY A MILITARY COURT-MARTIAL? (If no

AND ADDRESS OF THE MILITARY AUTHORITY OR COURT INVOLVED.

military service, answer "NO,")

YES

15A. ARE YOU NOW UNDER CHARGES

15B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURENCE, AND THE NAME

FOR ANY VIOLATION OF LAW?

AND ADDRESS OF THE MILITARY AUTHORITY OR COURT INVOLVED.

YES

16. HAVE YOU EVER BEEN SUSPENDED, EXPELLED OR ASKED TO RESIGN OR WITHDRAW FROM ANY EDUCATIONAL INSTITUTION, OR HAVE YOU RESIGNED

OR WITHDRAWN FROM ANY SUCH INSTITUTION IN TIME TO AVOID DISCIPLINE, SUSPENSION, OR EXPULSION FOR CONDUCT INVOLVING DISHONESTY, FRAUD,

MISREPRESENTATION, OR DECEIT?

YES

17. HAVE YOU EVER BEEN DISCIPLINED, REPRIMANDED, SUSPENDED OR TERMINATED IN ANY JOB FOR CONDUCT INVOLVING DISHONESTY, FRAUD,

MISREPRESENTATION, DECEIT, OR ANY VIOLATION OF FEDERAL OR STATE LAWS OR REGULATIONS?

YES

18. HAVE YOU EVER RESIGNED, RETIRED FROM, OR QUIT A JOB WHEN YOU WERE UNDER INVESTIGATION OR INQUIRY FOR CONDUCT WHICH COULD HAVE

BEEN CONSIDERED AS INVOLVING DISHONESTY, FRAUD, MISREPRESENTATION, DECEIT, OR VIOLATION OF FEDERAL OR STATE LAWS OR REGULATIONS, OR

AFTER RECEIVING NOTICE OR BEING ADVISED OF POSSIBLE INVESTIGATION, INQUIRY, OR DISCIPLINARY ACTION FOR SUCH CONDUCT?

YES

19. HAVE YOU EVER FUNCTIONED AS A REPRESENTATIVE, AGENT, OR ATTORNEY BEFORE A STATE OR FEDERAL DEPARTMENT OR AGENCY?

YES

VA FORM 21a, MAY 2007, PAGE 2

Application For Accreditation As A Claims Agent Or Attorney Page 2

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