Application for Veterans' Preference

This printable "Application for Veterans' Preference" is a document issued by the U.S. Office of Personnel Management specifically for United States residents.

Download a PDF of the latest edition of the form down below or find it through the department's forms library.

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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
To
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
--------------------------------------------------------------------
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
--------------------------------------------------------------------
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
No
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
(c) If married now, is your husband
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
to
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
Page 1 of 2
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
To
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
--------------------------------------------------------------------
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
--------------------------------------------------------------------
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
No
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
(c) If married now, is your husband
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
to
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
Page 1 of 2
DOCUMENTATION REQUIRED – READ CAREFULLY
Please submit photocopies of documents because they will not be returned unless a certified copy is specified.
A. Documentation of Service and Separation under Honorable Conditions
Please Note: When a veteran dies on active duty, the family does not receive a DD Form 214;
the family receives a DD Form 1300, Report of Casualty, on which there is no place to record the
Submit any of the documents listed below as documentation, provided they are dated on or
character of service. Thus, when a veteran dies on active duty, his or her service should be
after the day of separation from active duty military service:
presumed to be under honorable conditions unless the military service specifically indicates
otherwise.
1. Honorable or general discharge certificate.
2. Certificate of transfer to Navy Fleet Reserve, Marine Corps Fleet Reserve, or enlisted
C. Documentation of Veteran’s Death
Reserve Corps.
3. Orders of transfer to retired list.
1. If on active military duty at time of death, submit official notice, from a branch of the
4. Report of separation from a branch of the Armed Forces.
Armed Forces, of death occurring under honorable conditions.
5. Certificate of service or release from active duty, provided honorable separation is
2. If death occurred while not on active duty, submit certified copy of death certificate.
shown.
6. Official statement from a branch of the Armed Forces showing that honorable separation
D. Documentation of Service or Death During a War, in a Campaign or Expedition for
took place.
which a Campaign Badge is Authorized, or During the Period Authorized, or During
7. Notation by the Department of Veterans Affairs or a branch of the Armed Forces on an
the Period of April 28, 1952, through July 1, 1955.
official statement, described in B below, that the veteran was honorably separated from
military service.
Submit documentation of service or death during a war or during the period April 28, 1952,
8. Official statement from the Military personnel records center that official service records
through July 1, 1955, or during a campaign or expedition for which a campaign badge is
show that honorable separation took place.
authorized.
B. Documentation of Service-Connected Disability; Purple Heart; and Nonservice-
E. Documentation of Deceased or Disabled Veteran’s Mother’s Claim for Preference
Connected Disability Pension.
because of Her Husband’s Total and Permanent Disability.
Submit one of the documents:
Submit a statement from husband’s physician showing the prognosis of his disease and
percentage of his disability.
1. An official statement, dated 1991 or later; from the Department of Veterans Affairs or
F.
Documentation of Annulment of Remarriage by Widow or Widower of Veteran.
from a branch of the Armed Forces, certifying to the present existence of the veteran’s
service-connected disability.
2. An official citation, document or discharge certificate, issued by a branch of the Armed
Submit either:
Forces, showing the award to the veteran of the Purple Heart for wound or injuries
received in action.
1. Certificate from the Department of Veterans Affairs that entitlement to pension or
3. An official statement, dated 1991 or later; from the Department of Veterans Affairs,
compensation was restored due to annulment.
certifying that the veteran is receiving a nonservice-connected disability pension,
2. A certified copy of the court decree of annulment.
compensation for a service-connected disability or disability retired pay.
G. Documentation of Service During War or Certain Periods of Time.
4. An official statement or retirement orders from a branch of the Armed Forces showing
that the retired serviceman was retired because of permanent, service-connected
disability or was transferred to the permanent disability retirement list.
Submit a DD-214 or other documentation that establishes entitlement to a preference
described in Section 9. Note: A campaign medal holder or Gulf War veteran who originally
For spouses and mothers of disabled veterans who checked item 10 or 12, submit the following:
enlisted after Sep 7, 1980, (or began active duty on or after 14 October 1982, and has not
previously completed 24 months of continuous active duty) must submit documentation
An official statement, dated 1991 or later, from the Department of Veterans Affairs or from a
establishing 24 months of continuous service or service for the full period for which called or
branch of the Armed Forces, certifying:
ordered to active duty. The 24-month service requirement does not apply to preference
eligibles separated for disability incurred or aggravated in the line of duty, or to veterans
1) the present existence of the veterans service-connected disability,
separated for hardship or other reasons under 10 U.S.C. 1171 or 1173.
2) the percentage and nature of the service-connected disability or disabilities (including the
H. Documentation of Veteran’s Inability to Work Because of a Service-Connected
combined percentage),
3) a notation as to whether the service-connected disability is rated as permanent and total.
Disability
Answer questions 1-7 below:
1. Is the veteran currently working? If No, go to Item 3.
2. If currently working, what is the veteran’s present occupation?
Yes
No
3. What was the veteran’s occupation, if any, before military service?
4. What was the veteran’s military occupation at the time of
separation?
5. Has the veteran been employed, or is he/she now employed, by the Federal civil service or D.C. Government?
Yes
No
A. Title and Grade of position most recently or currently, held
B. Name and address of agency
C. Dates of Employment
From:
To:
6. Has the veteran resigned from, been disqualified for, or separated from a position in the Federal civil service or D.C. Government along the lines of his/her usual occupation because of service-
connected disability?
If Yes, submit documentation of the resignation, disqualification, or separation.
Yes
No
7. Is the veteran receiving a civil service retirement pension?
CSA #
If Yes, give the Civil Service annuity or Federal employee retirement annuity number.
Yes
No
Page 2 of 2

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