Fillable Standard Form 15 - Application For 10-Point Veteran Preference printable pdf download

APPLICATION FOR 10-POINT VETERAN PREFERENCE

(TO BE USED BY VETERANS & RELATIVES OF VETERANS)

Form Approved:

U.S. Office of Personnel Management

O.M.B. No. 3206-0001

PERSON APPLYING FOR PREFERENCE

2. Name of Civil Service or Postal Service exam and/or job announcement

1. Name (Last, First, Middle)

number you have applied for or position which you currently occupy

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

4. Date exam was held or 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 10-POINT 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 5 CFR Part 211. All conditions

are not fully described on this form because of space restrictions. You should submit this completed form to the agency to which you are applying. They can also provide any additional information.)

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 disability pension under public laws administered by

A and B

the VA.

9. Veteran's Claim for Preference based on eligibility for or receipt of compensation from the

-- -- -- -- -- -- -- -- -- -- -- -- -- ---- -- →

VA or disability retirement from a Service Department for a 10% or more service-connected

A and C

disability.

Yes

a. Are you presently married to the

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

veteran?

of a service-connected disability, has been unable to qualify for a Federal or D.C.

C and H

Government job, or any other position along the lines of his/her usual occupation. (If your

answer to item A is No, you are ineligible for preference and need not submit this form.)

a. Were you married to the veteran

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

when he or she died?

A, D, E, and G

(If your answer is No to item A or Yes to item B, you are ineligible for preference and need

not submit this form).

(Submit G when applicable.)

b. Have you ever remarried? Do not

count marriages that were

annulled.

a. Are you married?

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

Disabled Veteran

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

C, F, and H

veteran, and

(Submit F when applicable.)

b. Are you separated? If Yes, do not

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

complete C, go to D.

permanently disabled, or

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

c. If married now, is your husband

Deceased Veteran

remarried, or

totally and permanently disabled?

A, D, E, and F

(Submit F when applicable.)

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

d. If the veteran is dead, did he/she

widowed, divorced, or separated from the husband of your remarriage. (If your answer is

die in active service?

No to item C or D, you are ineligible for preference and need not submit this form.)

PRIVACY ACT AND PUBLIC BURDEN STATEMENT

The Veterans' Preference Act of 1944 authorizes the collection of this information. The information will be used, along with any accompanying documentation to determine whether you are

entitled to 10-point veterans' preference. This information may be disclosed to: (1) the Department of Veterans Affairs, or the appropriate branch of the Armed Forces to verify your claim; (2)

a court, or a Federal, State, or local agency for checking on law violations or for other related authorized purposes; (3) a Federal, State, or local government agency, if you are participating in

a special employment assistance program; or (4) other Federal, State, or local government agencies, congressional offices, and international organizations for purposes of employment

consideration, e.g., if you are on an Office of Personnel Management or other list of eligibles. Failure to provide any part of the information may result in a ruling that you are not eligible for

10-point veterans' preference or in delaying the processing of your application for employment.

Public burden reporting for this collection of information is estimated to take approximately 10 minutes per response, including time for reviewing instructions, searching existing data sources,

gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of

information, including suggestions for reducing this burden to OPM Forms Officer, U.S. Office of Personnel Management, Washington, D.C. 20415; The OMB Number, 3206-0001, is currently

valid. OPM may not collect this information and you are not required to respond, unless this number is displayed.

I certify that all of the statements made in this claim 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 10-Point preference

Preference entitlement was verified

Date signed

Name of Agency

Signature of person claiming preference

(Month, Day, Year)

Title of Appointing Officer

Date signed

FOR USE BY APPOINTING OFFICER ONLY

Signature of Appointing Officer

(Month, Day, Year)

Standard Form 15