Application For Accreditation As A Claims Agent Or Attorney Page 3
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420. HAVE YOU EVER BEEN REPRIMANDED, SUSPENDED, OR BARRED FROM PRACTICE BEFORE ANY COURT, BAR, OR FEDERAL OR STATE
AGENCY, OR HAVE YOU RESIGNED MEMBERSHIP IN THE BAR OF ANY COURT, OR FEDERAL OR STATE AGENCY TO AVOID REPRIMAND, SUSPENSION, OR
DISBARMENT FOR CONDUCT INVOLVING DISHONESTY, FRAUD, MISREPRESENTATION, OR DECEIT?
YES
NO
21. HAVE YOU EVER APPLIED FOR ACCREDITATION BY THE DEPARTMENT OF VETERANS AFFAIRS AS A REPRESENTATIVE OF A VETERANS SERVICE
ORGANIZATION, AGENT, OR ATTORNEY?
YES
NO
22. IF YOU WERE PREVIOUSLY ACCREDITED AS A REPRESENTATIVE OF A VETERANS SERVICE ORGANIZATION, WAS THAT ACCREDITATION TERMINATED OR
SUSPENDED AT THE REQUEST OF THE ORGANIZATION?
YES
NO
23A. DO YOU HAVE ANY CONDITION OR IMPAIRMENT (SUCH AS SUBSTANCE ABUSE, ALCOHOL ABUSE, OR A MENTAL, EMOTIONAL, NERVOUS, OR
BEHAVIORAL DISORDER OR CONDITION) THAT IN ANY WAY CURRENTLY AFFECTS, OR, IF UNTREATED OR NOT OTHERWISE ACTIVELY MANAGED, COULD
AFFECT YOUR ABILITY TO REPRESENT CLAIMANTS IN A COMPETENT AND PROFESSIONAL MANNER?
YES
NO
23B. IF YOU ANSWERED "YES," TO ITEM 23A, PLEASE DESCRIBE THE CONDITION OR IMPAIRMENT, AND ANY TREATMENT YOU RECEIVED IN THE PAST YEAR
OR RECEIVE NOW. IF YOU HAVE BEEN UNDER THE CARE OR SUPERVISION OF A HEALTH-CARE PROFESSIONAL, SUBMIT A STATEMENT BY THE HEALTH-CARE
PROFESSIONAL SPECIFYING YOUR CURRENT DIAGNOSIS, TREATMENT REGIMEN, AND PROGNOSIS, AND ITS BEARING ON YOUR FITNESS TO REPRESENT
CLAIMANTS BEFORE THE DEPARTMENT OF VETERANS AFFAIRS.
24A. DO YOU HAVE ANY PHYSICAL LIMITATIONS WHICH WOULD INTERFERE WITH YOUR COMPLETION OF A WRITTEN EXAMINATION ADMINISTERED UNDER
THE SUPERVISION OF A VA REGIONAL COUNSEL (Claims agent applicants only) ?
YES
NO
24B. IF "YES," PLEASE STATE THE NATURE OF SUCH LIMITATIONS AND PROVIDE DETAILS OF ANY SPECIAL ACCOMMODATIONS DEEMED NECESSARY.
25. CHARACTER REFERENCES
(Please provide the full names, addresses, and current phone numbers of three individuals who are not immediate family members and who have personal knowledge of
your character and qualifications to serve as a claims agent or attorney.)
PHONE NUMBER
RELATIONSHIP TO
NAME
ADDRESS
(Include area code)
APPLICANT
EXTENSION:
EXTENSION:
EXTENSION:
CERTIFICATION: I CERTIFY THAT the statements and entries on this form are true and correct. (A willfully false statement or certification is a
criminal offense and is punishable by law [18 U.S.C. 1001]).
SIGNATURE OF APPLICANT (Ink Signature)
DATE SIGNED
VA FORM 21a, MAY 2007, PAGE 3
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